Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0356, written 22 Oct 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 Oct 2021 |
|---|---|
| Reference | 2021-0356 |
| Deceased | Anthony Clacher |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | State Custody related deaths · Mental Health related deaths · Alcohol, drug and medication related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
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 form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rt Hon Sajid Javid MP, Secretary of State for Health and Social Care 2. Victoria Atkins MP, Minister for Prisons and Probation 3. , Chief Executive Officer of Her Majesty's Prison and Probation Service 4. 5. 1 CORONER , Chief Executive Officer of NHS England , Chief Executive Officer of NHS Digital I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset 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 the 26th March 2018, an investigation was commenced into the death of Anthony John Clacher, born on the 19th May 1981. The investigation concluded at the end of the Inquest on the 19th October 2021. The Medical Cause of Death was: The conclusion of the Inquest recorded by the jury was a narrative conclusion that Anthony , but he was not capable of forming an intention that the outcome be fatal due to his mental health state, lack of general observations and use of illicit substances. 4 CIRCUMSTANCES OF THE DEATH On the 21 st March 2018 Anthony, a serving prisoner at HMP Guys Marsh, was found in his cell, C43 on the Dorset Unit at the prison. 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 1. During the inquest evidence was heard that: i. ii. to be, across time of Anthony's death, At the the use of psychoactive substances was a problem at HMP Guys Marsh as it was, and continues Psychoactive substances were said to be the most dangerous drug in prison. They can have both physical and mental impact upon the user and in themselves can cause death as well as an increase in suicidal ideation. the prison estate. Approximately 2 hours 25 minutes before Anthony was found in his cell, he was found under the influence of psychoactive substances. He was attended upon by healthcare professionals and prison staff and placed in his cell. At the time there was no policy in place regarding welfare checks to be undertaken upon somebody found under the influence of psychoactive substances and the prison staff would rely upon guidance provided by the healthcare staff. iii. Observations afford the opportunity of monitoring the prisoners for physical and mental health deterioration and an opportunity to observe preparatory acts for self-harm. There are known risks associated with a person being found under the influence of psychoactive substances and they include the risk of vomiting and choking, seizures, heart attack or a significant deterioration in their mental health. iv. v. vi. There is no national guidance of how to monitor a person in prison once found under the evidence of psychoactive substances. they have been Following this, and other deaths associated with psychoactive substance use at HMP Guys Marsh, they have developed a local policy of prison officers undertaking welfare checks when a person is found under the influence of Psychoactive substances. In these circumstances a welfare checks log is started, and that person will initially remain under 15 minute observations. If there is no concern after an hour the observations will be reduced to hourly for a 24 hour period. Evidence was given that this has undoubtedly save lives at HMP Guys Marsh. In addition, HMP Guys Marsh have developed another local the Persistent Psychoactive Substances initiative called Intervention Plan (PPSIP). This initiative is used where a is using psychoactive substances persistently and prisoner therefore requires further support and monitoring due to an increased risk of harm. Evidence was given that this initiative has undoubtedly reduced deaths at HMP Guys Marsh. 2 vii. viii. ix. The third initiative HMP Guys Marsh has adopted under local procedures is the Custodial Officer Intermediate Life Support (COILS) initiative. This is a joint initiative between the healthcare and prison staff where the healthcare teams have trained the prison staff in life saving and supportive care. The staff are trained on certain medical processes including the ability to take vital observations, use certain medical equipment, for example a suction machine, and have access to an emergency kit bag to provide more than basic life support to prisoners. The benefits of this system are that the prison staff themselves can provide more advanced care in the absence of healthcare professionals. In addition, when healthcare professionals are in attendance, the healthcare professional can take the lead in advising and making decisions regarding care, whilst the support is provided by prison officers. It was described as similar to when a lead paramedic is on scene supported by paramedics and emergency care assistants. Evidence was again given that this has undoubtedly saved lives at HMP Guys Marsh. Evidence was given that the role out of these initiatives across all prisons in England and Wales would prevent future deaths. Those at HMP Guys Marsh and Practice Plus Group are happy to share their procedures and documents to assist in the rolling out of these processes at other establishments. further given that at HMP Guys Marsh Evidence was the healthcare provision is not available 24 hours per day, 7 days a week. At the time of Anthony's death, the healthcare provision was Monday to Friday, 7.30am to 6.00pm. Following Anthony's death healthcare is now available every day of the week but is not available between 6pm and 7.30am. If a medical event were to occur at the prison during these hours, the prison staff would be dependant on waiting for paramedic support. x. Whilst there has been the benefit of increased awareness and ability to deal with an emergency event due to the roll out of the COILS initiative, evidence was given by the Head of Healthcare at HMP Guys Marsh that medical events happen more frequently when healthcare is not on site during the evening hours. HMP Guys Marsh are discussing extending the healthcare hours until 10.00pm but this would still leave a lack of healthcare provision at HMP Guys Marsh between 10.00pm and 7.30am. xi. Practice Plus Group use SystmOne as a medical records system for those at HMP Guys Marsh as do all prison in the prison estate. Evidence was given by the Head of Healthcare that this system was designed for use in GP practice and not for use in prisons. Prisoners' medical records are often quite voluminous, and evidence was given that it is not possible to read the entirety of the records and therefore key words are searched to draw out the relevant information . Evidence was given that every entry is very important, and it is important not to miss vital information 3 xii. xiii. xiv. xv. xvi. xvii . especially in those high-risk individuals with complex needs. Evidence was given that whilst certain information can be very clear with SystmOne, complex information about emotional difficulties that prisoners may suffer for example is not the easiest to locate and can be missed. Evidence was given that it would be of benefit if SystmOne could be adapted so that key information could be flagged, marked or easily identifiable in order that vital information is not missed which could be central to the treatment of a prisoner and particularly their mental health. Evidence was given at the Inquest that PSI 64/2011 or the ACCT version 6 guidance does not give direction about the attendance of healthcare at ACCT reviews and most importantly at ACCT reviews where it is proposed to close the ACCT. Evidence was given throughout the Inquest that the input of the healthcare team is very important to the ACCT process and it was suggested that to provide direction that healthcare professionals are required to attend at all ACCT reviews especially those where it is to be closed is vital and this should be reflected in national guidance. Information was provided that the PSI 64/2011 is currently under review and that this could be addressed within new PSI and in a safety bulletin or update following the release of ACCT version 6 in July 2021. Evidence was also given that during the Covid-19 pandemic prisoner movements have been reduced which has meant that rather than prisoners arriving at HMP Guys Marsh on a several days a week there has tended to be the arrival of large cohorts of prisoners once a week. One example was given that 17 prisoners could arrive at the prison on the same day. Evidence was given that this has caused significant pressures to be placed upon the prison and healthcare staff to progress the prisoners through the reception area. As part of the reception process, prisoners undergo a healthcare screening. Evidence was given that it is simply not possible to review all the medical records of the prisoners arriving in these circumstances and this could therefore result in vital information being missed. It is unknown at this time whether the movement of prisoners in this way will continue beyond the Covid-19 pandemic. The Head of Healthcare at HMP Guys Marsh confirmed that as you cannot access a prisoner's records until they arrive, there is a risk of future deaths given the fact that they simply do not have the capacity to review the all healthcare records at the point of reception. 4 2. I have concerns with regard to the following: i. ii. iii. iv. v. There could be future deaths across the prison estate nationally due to a lack of observations and welfare checks upon prisoners who are found under the influence of Spice and I request consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of their Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP) and the Custodial Officer Intermediate Life Support initiative (COILS). I have concerns that future deaths could occur due to the lack of 24 hour healthcare across the prison estate. I would therefore request consideration be given to the provision of healthcare to all prisons 24 hours a day, 7 days a week. I have concerns that future deaths could occur due to the lack of attendance of healthcare staff at ACCT reviews, especially where the ACCT is closed. I request that consideration is given to providing guidance nationally by way of a safety bulletin or an update to the ACCT version 6 guidance and in the new PSI to be released in the future on the policy on management of prisoners at risk of harm to self, to others and from others, ensuring the attendance of healthcare staff at all ACCT reviews. that vital I am concerned information contained within a prisoner's medical health records stored on SystmOne, could be missed due to fact the software is more adapted to GP practice than prison healthcare. This could result in a future death and I request consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable and highlighted to avoid crucial information regarding a patient's care and safety being missed. I have concerns with the movement of prisoners around the prison estate in large cohorts as it could result in information regarding a prisoner's health not being identified which could result in a lack of healthcare provision to the prisoner which could result therefore request that consideration be given to the review of the processes when large cohorts are received at prisons and the resources available to prison and healthcare staff prior to the arrival of the prisoner and during the progression of the prisoners through the reception process. in a future death. I 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or vour oroanisation have the power to take such action. 5 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, 17th December 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: (1) Irwin Mitchell Solicitors on behalf of Anthony's family (2) Hill Dickinson LLP, of behalf of Practice Plus Group, EDP, Midlands Partnership NHS Foundation Trust. (3) Government Legal Department, One Kemble Street, London, WC2B 4TS on behalf of the Ministry of Justice (4) Radcliffes Le Brasseur LLP on behalf of Central and North West 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 Dated 22nd October 2021 Signed ti3i ~ 5 ~ .., Rachael C Griffin ' • 6
4 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.
• Department of Health & Social Care Ms Rachael Clare Griffin HM Senior Coroner, Dorset HM Coroner's Office Bournemouth Town Hall Bournemouth BH2 6DY Dear Ms Griffin, From Gillian Keegan MP Minister of State for Care and Mental Health 39 Victoria Street London SW1HOEU 21 January 2022 Thank you for your letter of 22 October 2021 to Sajid Javid about the death of Anthony Clacher. I am replying as Minister with portfolio responsibility for prison healthcare and I would like to express my deep condolences to Mr Clacher's family and loved ones at what must be a difficult time. NHS England and NHS Improvement (NHSEI) is responsible for the commissioning of healthcare for the prison estate. I am aware that NHSEI has provided a response to you on the matters of concern in your report relating to healthcare. I will not repeat the detail of that response. However, I offer the following comments. Firstly, 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. As a signatory to the National Partnership Agreement (NPA) for Prison Healthcare1, the Department of Health and Social Care is committed to working with the Ministry of Justice, Her Majesty's Prison and Probation Service (HMPPS), NHS England and NHS Improvement (NHSEI), the UK Health Security Agency (UKHSA) and the Office for Health Improvement and Disparities (OHIO), 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 a 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. During custody, healthcare providers in prison should have robust processes in place to identify, assess and treat offenders with mental health or substance misuse needs. 1 National Partnership Agreement for Prison Healthcare in England 2018-2021 (publishing.service.gov.uk) Decisions about whether to provide treatment are made on the basis of an identified clinical need. In relation to healthcare participation in the Assessment, Care in Custody and Teamwork (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. Responsibility for the ACCT process lies with HMPPs and I am informed that it will respond to you more fully on this matter. In relation to the electronic patient record platform used in the prison estate (SystmOne), I understand that it has been adapted for use in this setting with specific templates for example, to support the reception of prisoners. The integrated summary care record that provides key patient information to clinicians is also accessible. I am advised that further improvements are planned, including linking the SystmOne platform to the National Offender Management Information System (NOMIS) . During the COVID-19 pandemic, NHSEI and Public Health England , 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. In addition, you may wish to note that since November 2020, the Digital Person Escort Record (dPER), which is accessible to healthcare staff prior to a prisoner transfer and highlights risks and key information, has been available across the prison estate, to support the reception process. More generally, I would like to assure you that we recognise that substance misuse in the prison estate presents real challenges for both healthcare and prison staff. Restricting supply and reducing demand for drugs and building recovery from substance misuse is vital to ensure safe and productive prisons and to reduce reoffending . NHSEI commission services which are designed to enable local delivery, tailored to the specific challenges experienced by individual establishments. NHSEI published a revised service specification for Integrated Substance Misuse Services in Prison 2 which describes a recovery orientated, integrated prison substance misuse treatment service. The specification covers traditional drugs of abuse, psychoactive substances, illicit abuse of prescribed and over the counter drugs, and alcohol. The use of a range of psychoactive substances has presented considerable additional challenges to all staff working in prisons due to the wide ranging and unpredictable effects of these drugs, particularly synthetic cannabinoids. Psychoactive substance use can be effectively treated through psychosocial interventions . However, preventing initial or ongoing use is key, through treatment which aids desistance, and working with individuals to manage triggers and prevent relapse are all important. Otherwise, the primary treatment returns to symptom control and crisis management. 2 NHS England» Service specification: Integrated Substance Misuse Treatment Service in Prisons in England I can confirm that NHSEI is working closely with HMPPS to ensure establishment-level resilience to psychoactive substances, through a co-ordinated approach to both supply and demand reduction.·. 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 2 February 2022 Mrs Rachel C Griffin Senior Coroner for Dorset Bournemouth Town Hall Bournemouth BH2 6DY Dear Ms Griffin Thank you for your Regulation 28 report of 22 October 2021 following the inquest into the death of Anthony Clacher at HMP Guys Marsh on 21 March 2018. I am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS) as the Director General of Prisons. I apologise for the late return of this response. I know that you will share a copy of this response with the family of Mr Clacher 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 several concerns and I will address those which relate to the prison service. I understand that NHS England and NHS Improvement (NHSE/I) are responding separately on healthcare related matters for which they have responsibility. I thank you for bringing your concerns to my attention. The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe. The second concern you raise is in relation to healthcare attendance at ACCT reviews. I understand that evidence was heard at the inquest about the new version of ACCT (ACCT v6) which was rolled out nationally in July 2021. The ACCT v6 guidance is clear that case reviews must be multi-disciplinary and that healthcare staff must be invited to attend the first ACCT case review, as well any subsequent reviews where healthcare involvement is relevant to supporting an individual. Attendance at case reviews must be driven by the individual’s specific needs and support required to ensure consistency and continuity of care as the case review team work together to drive meaningful outcomes and take ownership for their assigned Support Actions. Team members should try to attend case reviews in person, however, where this is not possible they can still contribute through the written contribution form which is included in the ACCT documentation. ACCT user guidance was issued to all establishments in advance of the roll out of ACCT v6 to ensure that staff were familiar with the new version and confident with the key changes made to the document. All establishments were provided with bite size awareness training packages to deliver to staff and upskilling materials to equip staff with the necessary skills to complete ACCT V6, and revised training modules are being rolled out nationally for all staff involved in the delivery of ACCT. The third concern you have raised is that, as a result of the pandemic, prisoners have been arriving into prisons in large cohorts and this has put additional pressure on the reception procedures for prison and healthcare staff. While I recognise that this added to the pressures on staff assessing prisoners coming into prison, this has been necessary in order to keep prisoners safe, manage infection rates in line with public health advice, and to ensure that prisoners are receiving as full a regime as possible. This has only been possible through a cohort of prisoners arriving into prisons at the same time to begin a period of reverse cohorting together. As we begin to move away from the exceptional delivery measures, efforts are being made to transfer prisoners in smaller numbers and the aim is to return to standard delivery as was in place pre-pandemic. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised. Yours sincerely Director General of Prisons
Rachael C Griffin HM Senior Coroner for Dorset The Coroner’s Office for the County of Dorset Bournemouth Town Hall Bournemouth BH2 6DY 7 & 8 Wellington Place Leeds LS1 4AP 14 December 2021 Dear Ms Griffin NHS Digital Response to Regulation 28 Report – inquest touching the death of Anthony John Clacher I am writing in response to the Regulation 28 Prevention of Future Deaths report received from HM Senior Coroner dated 22nd October 2021. This follows the death of Anthony John Clacher who sadly passed away on 21st March 2018. This was followed by an investigation and inquest which concluded on 19th October 2021. Unfortunately, NHS Digital was not informed that this inquest was occurring, and did not have the opportunity to provide information and address your concerns directly. I am Digital. and am writing in my capacity as Director of Primary Care Technology at NHS I would like to express my sincerest condolences to Anthony’s family. The Regulation 28 Prevention of Future Deaths report outlines five matters of concern. We do not consider that matters of concern i, ii, iii or v relate to NHS Digital and thus have no comment on these. We respond below to matter of concern iv outlined in the report: www.digital.nhs.uk enquiries@nhsdigital.nhs.uk I am concerned that vital information contained within a prisoner’s medical health records stored on SystmOne, could be missed due to the fact that the software is more adapted to GP practice than prison healthcare. This could result in a future death and I request consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable and highlighted to avoid crucial information regarding a patient’s care and safety being missed. 1) The IT system used in HM Prison and Probation Service (HMPPS) healthcare settings is known as the health and justice information service (HJIS). HJIS is provided by an independent private sector IT supplier called TPP (tpp-uk.com) pursuant to a contract with NHS England and Improvement (NHSEI). HJIS is a modified version of TPP’s SystmOne product. 2) NHS Digital operates the Digital Care Services (DCS) catalogue, which includes the GPIT Futures catalogue. GPIT Futures enables GP users to buy assured digital tools and systems through approved assurance frameworks, and the framework agreement establishes a national GPIT framework between NHS Digital and the suppliers which provide IT services to GPs. TPP is one such supplier, and this is the route through which the standard SystmOne product is available to GPs. 3) The specification and contract for HJIS are bespoke for HMPPS and it was not procured through the GPIT Futures framework. 4) Policy for HJIS is set by NHSEI. 5) Therefore, NHS Digital is unable to comment further on the current design and functionality for HJIS. 6) NHS Digital are however supporting the HJIS team in NHSEI to set up a competitive re- procurement in 2022/23 for HJIS and it is possible that the re-procurement will be done through NHS Digital’s Digital Care Services catalogue. If so this would make NHS Digital the contract authority in future. 7) As part of supporting the re-procurement NHS Digital will consider this matter of concern when developing of the set of capabilities for the HJIS re-procurement, and additionally would welcome the opportunity to speak to the witness that made the observations about SystmOne in order to gather more detailed input. 8) Additionally, NHS Digital is currently supporting HJIS in the following related ways, and considers that these activities will also support improved access to a patient’s medical records within the HMPPS estate and between this and wider primary care: a. to adopt other GP IT related products such as GP2GP which is a cross-system standard used to enable patient records to be transferred electronically between GP system suppliers as they move practices. Patient records are not currently transferred into HJIS when an individual moves into the detained estate, but they will do so once this is enabled during FY22/23; b. to adopt the GP registrations system used in England to track the organisation responsible for a patient’s care. Presently HMPPS do not use the existing system, www.digital.nhs.uk enquiries@nhsdigital.nhs.uk known as NHAIS (National Health Application and Infrastructure Service), but will adopt the new system, to be known as Primary Care Registration Management system, when it is delivered in FY22/23; and c. support for the HJIS transformation programme which is currently being led by North of England Commissioning Support Unit (NECS) and is responsible for rolling out new Spine functionality to all of the detained estate sites. If I can be of any further assistance, please let me know. Yours sincerely Director of Primary Care Technology NHS Digital www.digital.nhs.uk enquiries@nhsdigital.nhs.uk
Ms R. C. Griffin Senior Coroner Coroner’s Office for the County of Dorset Bournemouth Town Hall, Bournemouth, BH2 6DY National Medical Director & Interim Chief Executive, NHSI NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH 30th November 2021 Dear Ms Griffin, Re: Regulation 28 Report to Prevent Future Deaths – Mr Anthony John Clacher; date of death 21 March 2018, HMP Guy’s Marsh. Thank you for your Regulation 28 Report dated 22nd October 2021 concerning the death of Mr Anthony John Clacher on 21 March 2018. Firstly, I would like to express my sincere condolences to Mr Clacher’s family. I note that the recent investigation into Mr Clacher’s death concluded that his death was self-inflicted as a result of the inquest, you have raised concerns within your Regulation 28 Report to NHS England, about a number of areas. I have listed these below along with the NHS England and NHS Improvement response to each. and following the conclusion of NHS England and NHS Improvement is the responsible organisation for the commissioning of healthcare into prisons, which is devolved to seven regional teams. Commissioning healthcare in prisons is done on a principle of equivalence, which has been defined by the Royal College of General Practitioners. This definition broadly states that the aim is to ensure people detained in prisons in England, are afforded provision of and access to appropriate services and treatment that is considered to be at least consistent in range and quality, with that available in the wider community. 1. Consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP), and the Custodial Officer Intermediate Life Support initiatives (COILS). I understand that Her Majesty’s Prison and Probation Service (HMPPS) will provide a full response to this as the responsible organisation. NHS England and NHS Improvement 2. Consideration be given to the provision of healthcare to all prisons 24 hours a day, 7 days a week All prisons have a health needs assessment (HNA) carried out prior to services being commissioned. This ensures the correct level of healthcare is delivered for the population need. All prisons have some healthcare services on-site and reception prisons (those sites which provide a service to the courts and effectively manage remand prisoners and those with a very short time to serve) have 24 hours a day, 7 days a week (24/7) healthcare. Other sites would only have this 24/7 service commissioned on-site where there was a significant call for it, which would be on the basis of an HNA (prisons with an aged demographic for instance). All women’s sites have 24/7 healthcare as all receive from court. Access to healthcare services is however available 24/7 using external services with all sites having access to out of hours (OOH) and emergency, GP and first responder services should they be required. 3. Consideration is given to providing guidance nationally by way of a safety bulletin or an update to the ACCT V6 guidance and in the new PSI to be released in the future on the policy on management of prisoners at risk of harm to self, to others and from others, ensuring the attendance of healthcare at all ACCT reviews. NHS England and NHS Improvement worked collaboratively with HMPPS to review the Assessment, Care in Custody and Teamwork (ACCT) process around healthcare attendance. It has been rolled out by HMPPS across the prison estate and evaluation is underway with findings due early 2022. Responsibility for this lies with HMPPS, and we have collaborated with HMPPs to agree that they will be responding in full to this point. 4. Consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable (sic) and highlighted to avoid crucial information regarding a patient’s care and safety being missed. The current SystmOne (S1) module that is used in prison is a bespoke system, already adapted for the secure estate. Although this is based on primary care, there have been a number of adaptions to make improvements to the suitability of the system for the secure environment. This includes specially designed templates at reception based on NICE guidance to gather key, pertinent information when someone arrives into prison for the first time, as well as bespoke prescribing modules. All sites have access to the integrated summary care record which houses the latest information regarding a patient’s significant health such as Diabetes, Mental health, for instance, along with regular medication and allergies. This is the same functionality available to other clinicians outside which can be accessed to verify the patient’s condition at that time. If the patients GP is also using TPP S1 and has the functionality set to share out the medical record, this can be seen in the tabbed journal when the patient is registered on the TPP S1 unit on arriving at the prison. Further improvements are planned over the next year to include the ability to link with PNOMIS and the capacity to access community records through GP2GP electronic transfer and, from 2022 should a patient wish to register with the detained estate as their GP practice the full medical record will be sent to the prison via GP2GP. 5. Consideration be given to the review of processes when large cohorts are received at prisons and the resources available to prison and healthcare staff prior to arrival of the prisoner and during the progression of the prisoners through the reception process. Progress in this area has already been made. Digital Person escort record (DPER) has been live across the prison estate since November 2020. All reception healthcare staff should have access to the DPER prior to arrival of persons at the site. This platform highlights risks pertaining to patients arriving and can be used to ensure the correct processes are followed at reception for healthcare teams. Healthcare teams also have the ability to access the integrated summary care record (SCR) at reception to validate high level health issues and medication requirements. Further I can confirm that a review and update of the reception and secondary screening templates for healthcare is ongoing, and this is primarily within the female estate at present. This programme of work package will conclude by April 2022 and then, using lessons learned, the same system will be applied to the male estate during 2022. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director & Interim Chief Executive, NHSI
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