Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0180, written 22 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Apr 2021 |
|---|---|
| Reference | 2021-0180 |
| Deceased | Kelly Hewitt |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| Category | Mental Health related deaths · Suicide (from 2015) |
| Organisation named | East London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Rt Hon Lucy Frazer QC MP, Minister of State for Prisons, MOJ 1 CORONER I am Tom OSBORNE, Senior Coroner for the area of Milton Keynes 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 23rd December 2019 I commenced an investigation into the death of Kelly Francesca HEWITT aged 24. The investigation concluded at the end of the inquest on 01 April 2021. The conclusion of the inquest was: That she died from suicide. 4 CIRCUMSTANCES OF THE DEATH The deceased, a prison officer, was found on the 18th December 2018 hanging at her home at 32 Appledine Way, Bedford. Paramedics attended and she was confirmed dead. She had been suffering from depression. It was recognised by work colleagues and managers within the prison that she was suffering with her mental health. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: Concerns were expressed throughout the inquest as to the lack of mental health support available to prison officers. I believe that the provision of mental health support for prison staff should be reviewed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 08 June 2021. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; The Family East London NHS Foundation Trust. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Tom OSBORNE Senior Coroner for Milton Keynes Dated: 22 April 2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 25 May 2021 Mr Tom Osborne HM Senior Coroner for Milton Keynes HM Coroners Office, Civic Offices 1 Saxon Gate East Central Milton Keynes MK9 3EJ Dear Mr Osborne, Thank you for your Regulation 28 Report of 22 April 2021 addressed to the Minister of State for Prisons following the inquest into the death of Kelly Hewitt on 18 December 2018. I am responding as Director General for Prisons. I know that you will share a copy of this response with Ms Hewitt’s family, and I would like first to express my sincere condolences for their loss. You have expressed concern that members of staff described a lack of mental health support available to prison officers during the inquest and you have advised that the provision of mental health support for prison staff should be reviewed. I take these concerns very seriously and I am pleased to inform you that we have made substantial progress in improving support for prison staff since the sad death of Ms Hewitt. We now employ an Employee Psychological Support Services Clinical Lead who has responsibility for policy, strategy and clinical standards, making sure that the provision of mental health support services for staff is appropriate, accessible and effective. This qualified practitioner draws on expertise from a range of contracted and partner organisations to deliver an enhanced mental health support offering for our employees. “Reach Out, Saves Lives” staff suicide prevention campaign In September 2020, working with the Samaritans and the Zero Suicide Alliance, we launched a 12-month high-profile staff suicide prevention campaign. The campaign publicly demonstrates our commitment to creating a world where fewer people die from suicide, including our staff, and that we will not shy away from addressing difficult mental health subjects. Backed by the Lord Chancellor and me, the campaign is active in all prisons and encourages staff to “connect” with each other and to access sources of support in times of need, and provides employees with educational tools that better equip them to assist one another. Proactive support for staff: Reflective Sessions and learning opportunities All senior managers are to be routinely offered a proactive and preventative mental health support service called Reflective Sessions, and these are also being made available to staff more generally, including all prison officers. These sessions, delivered by a qualified counsellor from our Employee Assistance Provider, aim to reduce the possibility that staff will experience adverse wellbeing or mental ill health effects due to the challenges of their role and to help them to reflect on the more rewarding aspects of prison work. Roll out is progressing well since the launch in January 2021. Group reflective sessions are a common way for this initiative to be delivered – encouraging open dialogue between colleagues about mental health matters to break down the stigma and drive cultural change. From May 2021 we are also working in partnership with Remploy to provide learning opportunities for operational and policy leads on the latest workforce mental health research and clinical insights. The aim is to build our capability and make sure that policy design and operational delivery planning consider and are sensitive to the psychological impact of our work on individuals. As coronavirus restrictions ease, we will reinstate onsite mental health and resilience training workshops covering topics like suicide and self-harm awareness, bereavement, dealing with trauma and managing stress and depression. Confidential support available HMPPS provides a 24-hour helpline staffed by counsellors to provide advice and support on any personal or work-related matters via its Employee Assistance Provider. For staff who have suffered a work-related trauma, Cognitive Behavioural Therapy and Eye Movement and Desensitisation Therapy (EMDR) are also available. Post Incident Care Policy Review Our Post Incident Care Policy is currently being reviewed. The purpose of the policy is to clarify the roles and responsibilities of all internal and external stakeholders following traumatic incidents. Fast-track post trauma clinical interventions are already available through our occupational health and employee assistance programme providers and critical peer support roles such as prison Care Teams and Trauma Risk Management (TRiM) practitioners. The revised policy will set out mandatory actions for prisons following incidents and require additional training and support to be in place for staff in peer support roles to ensure that we are delivering responsive and high-quality support. Thank you again for bringing your concern to my attention. I trust that this response provides assurance that this is an issue that we take very seriously, and that appropriate action is being taken in prisons. Yours sincerely Director General for Prisons
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