Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0332, written 30 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 | 30 Sep 2021 |
|---|---|
| Reference | 2021-0332 |
| Deceased | Stephen Cope |
| Coroner | Dr Julian Morris |
| Coroner area | London Inner (South) |
| Category | State Custody related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A 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. Rt. Hon Robert Buckland QC MP, Lord Chancellor and Secretary of State for Justice, House of Commons, London, SW1A 0AA 2. Rt. Hon Sajid Javid MP, Secretary of State for Health and Social Care, Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU 3. 4. 0EB , Governor HMP Belmarsh, Western Way, Thamesmead,SE28 , Chief Executive, Oxleas, Pinewood House, Pinewood Place, Dartford, Kent, DA2 7WG 1 CORONER I am Dr Julian Morris, deputy coroner, for the coroner area of Inner London South 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 25 November 2019 I commenced an investigation into the death of Stephen David COPE. The investigation concluded at the end of the inquest on 29 September 2021. The conclusion of the inquest was: 1a Suspension. The jury reached the following conclusions: Mr Cope voluntarily committed suicide which ended his life. We feel that he performed this act whilst conscious of what he was doing, and he intended to end his life. We do not consider there is enough evidence to suggest the closure of the ACCT on 04/09/2019 directly contributed to Mr Cope's death. Similarly, we consider a lack of information sharing between the health, mental health, care staff did not contribute to Mr Cope's death, staff were adequately trained to support Mr Cope and the response, by staff to Mr Cope's assault was appropriate and did not contribute to his death. The degree of risk of suicide identified in the risk assessment was documented and understood based on what Mr Cope communicated at the time. 1 4 CIRCUMSTANCES OF THE DEATH Mr Cope died on 18th November 2019 at 17:48 in Belmarsh prison in his own cell block by suspension. Mr Cope was remanded to HMP Pentonville in relation to an offence of attempted murder. He was placed on an ACCT on 12th August due to suicidal thoughts - he was very stressed about his trail and missing his daughter. He then moved to HMP Belmarsh on 2nd September and referred to mental health team, substance misuse, counselling and general practitioner on 3rd September. Mr Cope was taken off the ACCT on 4th Sept and put on Sertraline. On 18th November 2019 Mr Cope remained in his cell whilst his inmates attended class and at 16:45 an officer found Mr Cope hanging from a ligature on the top bunk. 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 could 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 transfer and review of prisoners on an ACCT. I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her. For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event. However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual. The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT, which is there for their support and well-being, and I would suggest, given to easy manipulation I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 29th November 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 Cope Family HMP Belmarsh Oxleas NHS Trust I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 30/9/2021 Dr Julian Morris 3
2 responses 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.
From Gillian Keegan MP Minister of State for Care and Mental Health 39 Victoria Street London SW1H 0EU Dr Julian Morris HM Deputy Coroner, Inner London South Southwark Coroner’s Court 1 Tennis Street Southwark SE1 1YD Dear Dr Morris, 21 January 2022 Thank you for your letter of 30 September 2021 to Sajid Javid about the death of Stephen David Cope. I am replying as Minister with portfolio responsibility for prison healthcare and I am grateful for the additional time in which to do so. Firstly, I would like to express my deep condolences to Mr Cope’s family and loved ones at what must be a difficult time. I am clear that all individuals detained in custody are entitled to the same quantity and quality of health and social care services as individuals living in the community. It is essential that both the prisons service and the NHS, reflect carefully and take all the necessary learnings from Mr Cope’s death to improve the quality and safety of prisons and prison healthcare. As a signatory to the National Partnership Agreement (NPA) for Prison Healthcare1, the Department of Health and Social Care and the Office for Health Improvement and Disparities (OHID, previously Public Health England), are committed to working with the Ministry of Justice, Her Majesty’s Prison and Probation Service (HMPPS), NHS England and NHS Improvement (NHSEI), and the UK Health Security Agency, to ensure safe, legal, decent and effective care that improves health outcomes and reduces health inequalities for prisoners, and are working with our partners on the next version of the NPA, which will be ready for April 2022. All people in prisons should receive an early health assessment within the first 24 hours of entry. The initial assessment should be fully comprehensive to ensure that all the physical and health needs of an individual are identified and addressed at an early stage. 1 National Partnership Agreement for Prison Healthcare in England 2018-2021 (publishing.service.gov.uk) During custody, healthcare providers in prison should have robust processes in place to identify, assess and treat offenders with mental health needs. Decisions about whether to provide mental health treatment are made on the basis of an identified clinical need and treatments range from short-term interventions to ongoing support on the mental health caseload which may include access to a psychiatrist. During the COVID-19 pandemic, NHSEI and OHID have worked closely with HMPPS to ensure appropriate arrangements are in place for people in prison to continue to access the physical and mental health care services they need. Responsibility for the Assessment, Care in Custody and Teamwork (ACCT) process lies with HMPPS and I am aware that it has responded to you on this matter. A new version of the ACCT has been introduced with changes that include an increased emphasis on information sharing, strengthened case reviews and post-closure procedures. In particular, I note that updated guidance accompanying the ACCT makes clear that when a change of circumstance takes place, such as transfer to another prison, an urgent case review must take place, prior to transfer, and as soon as possible at the receiving prison, informed by handover. In relation to healthcare participation in the ACCT process, and in particular, the consideration of closing an ACCT, I am advised that NHSEI has worked with HMPPS to review the ACCT process and healthcare attendance and findings are anticipated in early 2022. I hope this response is helpful. Thank you for bringing these concerns to my attention. GILLIAN KEEGAN
Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 24 December 2021 Dr Julian Morris Deputy Coroner Inner London South Southwark Coroner's court 1 Tennis Street London SE1 1YD Dear Dr Morris Thank you for your Regulation 28 report of 30 September 2021 following the inquest into the death of Stephen Cope at HMP Belmarsh on 18 November 2019. I am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS) as the Director General of Prisons. I know that you will share a copy of this response with the family of Mr Cope and I would like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. Following evidence heard at the inquest you have raised a concern in relation to the transfer and review of prisoners on an open ACCT and have suggested a set review period to allow time for support services to meet with and interview the transferred individual before an ACCT is closed. I thank you for bringing your concern to my attention. You may be aware that HMPPS has developed a revised version of ACCT, known as ACCT version 6, (ACCT V6) that was implemented across the prison estate in July 2021. The changes introduced in this new version are intended to assist staff to provide high quality multi-disciplinary care and support to individuals at risk, focusing on a person-centred approach which meets the needs of each individual. Some of the key changes include an emphasis on information sharing, improved case reviews and a strengthened post-closure period. As a key aim of ACCT is to focus on the needs of the individual, we do not believe that it is appropriate to mandate a period during which an ACCT cannot be closed. However, I wish to assure you that the processes in place work to provide the support needed in order to reduce the risk of self-harm and suicide and to ensure that an ACCT is not closed until it is considered safe to do so. Reviews should be multi-disciplinary, with attendance determined by the identified needs of the individual. Documents should not be closed on the basis only of the answers that a prisoner gives to any specific questions, and staff should not rely solely on an individual’s presentation when making judgements about risk. The ACCT v6 document now prompts for background information relating to risk to be recorded as part of the assessment process. Support actions are agreed, documented and updated during case reviews and should have clear outcomes and owners. Attendance at case reviews should include those responsible for actions and the support plans should identify all immediate and long-term risks, and the actions taken to mitigate them. The ACCT process should continue to be conducted in this way until all support actions are completed and the ACCT case review team feels that risk has reduced to a level at which the document can be closed. Once an ACCT has been closed, there is a mandatory seven day period of post-closure monitoring and a post-closure review is held, at which consideration is given to whether there needs to be any further post-closure reviews or whether the ACCT needs to be re- opened. Discussions and decisions are documented on the post-closure review form to ensure that there is a record of the reasons for the decision that has been made. An ACCT can then be re-opened if the level of risk changes and further support is required. We recognise that transferring to a new prison on an open ACCT is an uncertain time for prisoners, and that this can lead to an increased risk of suicide and self-harm. The updated ACCT v6 guidance that is now in place addresses this and makes clear to staff that when a change of circumstances occurs an urgent case review must take place. Such a review should take place prior to transfer to ensure that an individual’s level of risk has been properly considered and that observations remain set at an appropriate level in order to support the person. A review must also take place at the new establishment as soon as possible, informed by a handover from the transferring establishment. A learning bulletin about transferring prisoners on an open ACCT which emphasises the importance of good communication and information-sharing has been shared with all establishments and is available on the HMPPS intranet. Therefore, if the process is followed effectively and defensible decisions are made based on effective risk assessment then a mandatory period of monitoring for those who transfer on an open ACCT should not be required. The ACCT document will not be closed until all support actions have been completed and there is multi-disciplinary agreement that the level of risk has reduced. Thank you again for bringing your concern to my attention. I trust that this response provides assurance that the measures that we have introduced as part of ACCT v6 are sufficient to address the matter of concern that you have raised. Yours sincerely Director General of Prisons
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