Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0311, written 17 Sep 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Sep 2021 |
|---|---|
| Reference | 2021-0311 |
| Deceased | Colin Blackburn |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | State Custody related deaths · Mental Health related deaths |
| Organisation named | Midlands Partnership University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Governor, HMP Hewell, Hewell Lane, Redditch, Worcestershire; 2. The Head of Healthcare at HMP Hewell, c/o Practice Plus Group. 1 | CORONER | am David Donald William Reid, Senior Coroner, for the coroner area of Worcestershire. 2 | CORONER’S LEGAL POWERS | 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 11.7.19 an investigation was commenced into the death of Colin BLACKBURN, a prisoner at HMP Hewell, who died at the prison on 6.7.19, being 53 years of age. This investigation concluded at the end of the inquest on 16.9.21. The medical cause of death was: 1a ligature suspension. The conclusion of the inquest was as follows: “Colin Blackburn died as a result of deliberately suspending himself by a ligature. It is not possible to determine what his intention was at the time he did this. A failure adequately to assess Colin Blackburn's risk of suicide and/or self-harm at the case review of 4.7.19 probably caused or contributed to Mr. Blackburn's death. A failure to take sufficient action to meet the risk of suicide and/or self-harm which Mr. Blackburn presented at the case review of 4.7.19 probably caused or contributed to Mr. Blackburn's death.” 4 | CIRCUMSTANCES OF THE DEATH At the time of his death Mr. Blackburn had spent 15 days on remand at HMP Hewell awaiting trial in respect of an offence of serious violence. An ACCT document had been opened on the day he arrived at the prison, as he had expressed thoughts of taking his own life; this remained open until his death. In those 15 days, there were 3 separate incidents in which Mr. Blackburn was found with a ligature around his neck. He spent some 8 days in the Inpatients Unit, initially on constant watch, after the first of those incidents. His death on 6.7.19 therefore represented the fourth occasion on which he had self-ligatured. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — 1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Bl ackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19; (b) that no entries were made on the Care Map until 26.6.19; (c (d ) that no triggers or warning signs have been entered on the ACCT'’s inside cover; ) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on Qhel9} (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; ) that the Care Map was not reviewed at some ACCT Case Reviews; ) that those conducting ACCT Case Reviews did not familiarize themselves sufficiently with the ACCT document beforehand; that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j)_ that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn's NOMIS record; ) that no ACCT Case Review took place after the first ligature incident on 2.7.19; that there was no ACCT Case Review immediately before Mr. Blackburn's transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19; given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. | heard evidence that: - These issues arose because prison staff had so many demands on their time, mainly due to number of prisoners they had to deal with; - Since then, the population of the prison has reduced, and more new staff have been taken on; - Newsystems have been put in place regarding the management of ACCT document, the training for which was suspended during the Covid-19 pandemic; and - Anew version of the ACCT document was implemented in July this year, training for which has been provided to roughly a third of prison and healthcare staff at the prison. | am not satisfied that sufficient action has yet been taken to ensure that all members of prison staff understand their obligations in respect of prisoners who are subject to the ACCT process. This is because: (i) there is no evidence yet that the changes described above have led to a change in how prison staff deal with ACCT documents, and (ii) | heard evidence during the inquest from a number of senior officers who, even now, found it difficult to comprehend that their involvement with Mr. Blackburn and his ACCT document fell short of an acceptable standard. Ne 2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team, with the result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out. | heard evidence from the Head of Healthcare at the prison that urgent TAG referrals can currently be made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager. | received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no divert service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway. The paper referral system, which relies upon the internal post at the prison, is still in place although, | am told, it can be stopped. In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action by conducting an investigation into the deficiencies and failures outlined above. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12.11.21. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Hill Dickinson LLP, who represent Practice Plus Group; Capsticks LLP, who represent the Midlands Partnership NHS Foundation Trust; Government Legal Department, who represent HM Prison Service; The Prison and Probation Ombudsman. | 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. Signed D. D. W. Reid 17" September 2021 H.M. Senior Coroner for Worcestershire
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.
Practice Plus Group
Hawker House
5-6 Napier Court
Napier Road
Reading
Berkshire
RG1 8BW
practiceplusgroup.com
HM Senior Coroner for Worcestershire
Mr David Reid
Worcestershire Coroner’s Court
The Civic
Martins Way
Stourport-on-Severn
Worcestershire
DY13 8UN
2nd November 2021
Dear Sir
The Inquest touching upon the death of Mr Colin Blackburn
Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners
(Investigations) Regulations 2013 dated 17th September 2021 and following the inquest
touching upon the death of Mr Colin Blackburn, who sadly passed away at HMP Hewell on 6th
July 2019.
I would like to take the opportunity on behalf of Practice Plus Group to offer my sincere
condolences to Mr Blackburn’s family and friends for their loss.
This letter addresses the matters of concern insofar as they relate to Practice Plus Group.
Practice Plus Group is the main provider of healthcare services at HMP Hewell. There is a sub-
contracting arrangement in place with Midlands Partnership NHS Foundation Trust (‘MPFT’) in
respect of the provision of mental health services. The Regulation 28 report was not addressed
to MPFT although it has had sight of your report. This response has been prepared with the
input of members of staff working for MPFT at HMP Hewell. In the event that there are any
further specific operational queries relating to the mental health provision at HMP Hewell, I
respectfully request that such queries be directed to MPFT.
Matter of Concern
“On 4.8.19, a prison officer, who had concerns about a significant deterioration in Mr.
Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison
via the internal post. There was a delay in that referral reaching the Mental Team [sic], with the
result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the
court was told that an urgent mental health assessment would have been carried out. I heard
evidence from the Head of Healthcare at the prison that urgent TAG referrals can currently be
made by email, phone or on paper via internal post. If made late on a Friday or over a weekend,
there was no guarantee that the mental health team would pick up the referral until after the
weekend; instead, the referral should be made to a member of the healthcare team on duty that
weekend, who would then phone Practice Plus Group’s regional on-call manager.
Practice Plus Group Health and Rehabilitation Services Limited. Registered in England No 10498997
Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW
I received no assurance that prison staff wanting to make an urgent TAG referral over a
weekend knew that this was the process to follow, and heard that there is currently no diver
service in place, so that if a member of staff tries to make an urgent referral by phone or email
over the weekend, they are redirected to the correct pathway.
The paper referral system, which relies upon the internal post at the prison, is still in place
although, I am told, it can be stopped.
In my view, there remains uncertainty amongst staff at the prison about the right way to make
an urgent TAG referral to the mental health team, particularly at weekends. There is a risk
therefore that a prisoner whose mental health deteriorates significantly during a weekend may
not be properly assessed in time for action to be taken to address any risk of suicide or self-
harm which he may present.”
Response
The following actions have now been taken to address the concern raised.
1. The end date for the acceptance of paper referrals is 31st October 2021. From 1st
November 2021, paper TAGs (Threshold Assessment Grid)1 will cease to be an option
for referrals to the mental health team. The reason as to why this process could not
immediately be stopped is to allow for the transition from paper to paperless (and the
communication thereof) without incurring the additional risk of patients’ referrals being
missed. In this interim period paper TAGs are being accepted by the mental health team,
however, the individual who sends the TAG referral is then being asked to provide their
email address to which the electronic TAG is being sent along with guidance as to how
to use it, for their future reference, beyond 31st October 2021.
2. As part of this transition, posters have also been created to explain the process of
making electronic TAG referrals. These are now on display (laminated, A3 size)
throughout the prison. I enclose a copy of the poster with this response for your
information. This work has been undertaken in conjunction with the Prison’s Health &
wellbeing Governor.
3. Additionally, the posters referenced above confirm the following:-
a. The operational times for the mental health team;
b. The generic email address for the mental health team;
c. That all referrals must be sent electronically to that generic email address;
d. That the out of hours service to be provided using the primary healthcare team
as a gateway.
4. This same notice has also been sent via global email to all prison staff by the Governor’s
office.
5. All members of the mental health team have now added the following text to their email
signatures:-
1 A TAG is a short, quickly completed assessment of the severity of an individual’s mental health problems. The
scores range from none (no problem in that particular domain) to either severe or very severe. In each domain, the
person completing the assessment simply ticks the statement that best applies to the individual who is being
assessed.
Page 2 of 3
Please reply to our generic email mpft.inclusion.hewell@mpft.nhs.net The Mental
Health and Psychosocial Team at HMP Hewell is a Monday to Friday 9am - 5pm
service. MPFT operate an urgent care provision at weekends, our primary care
colleagues can escalate your concern via PPG on-call manager if required, please call
on 01527 785138.
This implementation was carried out immediately further to the conclusion of the inquest
touching upon the death of Mr Blackburn. In addition, all members of the mental health
team turn on an Out of Office message every evening, as well as weekends.
6. An out of office response has been added to the mental health team’s generic email
inbox at weekends, and is managed by the MPFT Administrator.
7. As an alternative to the electronic referral route for such times when a prison staff
member may not have immediate access to a computer, an answer phone has been
purchased for the mental health team and has been in utilisation since 13th October
2021. Whilst those incoming messages will be recorded, the voicemail auto-message
will be the same as the generic email out of office response (as above). The email
signatures of all members of staff within the mental health team display the generic
phone number, which reaches this phone (which now carries a voicemail facility). This
ensures that irrespective of whether a member of the mental health team is away from
his/her desk, the incoming call will be received by the admin team, for logging and
forwarding as appropriate.
I hope that the above information provides you with reassurance that action has been taken,
specifically to ensure that all staff at HMP Hewell are aware of the processes in place to ensure
that prisoners receive urgent mental health care at weekends, if the need arises.
Practice Plus Group is committed to ensuring the high quality provision of healthcare services
to all prisoners at HMP Hewell. We will also ensure that the lessons learnt as a result of this
inquest are implemented not only at HMP Hewell but across all of Practice Plus Group’s
services.
I do hope that this letter provided the necessary reassurance sought and if I can be of any
further assistance you should not hesitate to contact me directly.
Yours sincerely
National Medical Director, Health in Justice, Practice Plus Group
Page 3 of 3
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