Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0155, written 26 May 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 May 2022 |
|---|---|
| Reference | 2022-0155 |
| Deceased | Saifur Rahman |
| Coroner | James Bennett |
| Coroner area | Birmingham and Solihull |
| 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.
1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) Secretary of State for Justice, Ministry of Justice (2) Chief Executive, Birmingham and Solihull Mental Health Trust CORONER I am Mr James Bennett, HM Area Coroner for Birmingham and Solihull. 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. INVESTIGATION and INQUEST On 2 February 2021 I commenced an investigation into the death of SAIFUR RAHMAN. The investigation concluded at the end of a jury inquest held between 9-20 May 2022. CIRCUMSTANCES OF THE DEATH The jury’s factual finding: Saifur Rahman was a recognised drug user. It was reported that he was using mamba which contributed to the decline in his mental health. On the 16 November 2020, he was remanded at HMP Birmingham and on the 21 November he was admitted to the health care ward for a period of assessment. In early December he was diagnosed with Bi-polar disorder with mixed affective state and was treated with medication. Saifur Rahman's presentation on ward two was varied. At times he was amicable and would engage with others, at other times he was unpredictable and uncommunicative. He occasionally expressed odd beliefs and aggressive behaviours. However, he showed no self-harm or suicidal ideation. An A.C.C.T. was not considered necessary. In early January 2021 he was non-concordant with his medication. On 9 January he was moved to cell H3-15 due to damage and graffiti of his previous cell. On the 17 January, his unlock status was increased to custody manager plus three prison officers in full personal protective equipment. This was a consequence of his previous aggressive and anti-social behaviour. A relative telephoned the prison on 18 January, parties to the conversation report different accounts. However, it resulted in an application form for an additional number being added to Saifur Rahman's contacts. An officer presented the form at the cell and conducted a welfare check. The outcome of his last psychiatric assessment on 19 January was for Saifur Rahman to remain on healthcare, to record compliance with his medication and continue to monitor behaviour. The assessment raised no concerns regarding self- harm or suicidal ideation. Mr Rahman's presentation on the 20 January leading up to the incident raised no cause for concern. He was last seen alive at approximately 16:25 hours when he was delivered a meal through his cell door hatch. At approximately 17:00 hours during the medicine round, he could not be seen through the cell door hatch and he did not respond when called. The observation hole into the internal toilet recess had been damaged via a burn mark and crack. There was no evidence as to how or when this happened. The dome mirror was also missing, so it was not possible to see into the recess area. The prison officers expected to be assaulted on entering the cell, from the toilet recess. Therefore, unlock status was followed and cell entry occurred at around 17:13 hours. Mr Rahman was found He was lifted, placed on the floor and found to be in cardiac arrest. The prison officers commenced CPR. From the evidence given, it is likely that cardiac arrest occurred between 16:37 hours and 17:10 hours. The code blue call was delayed by up to a minute, but this did not contribute to his death. Prison nurses arrived and assisted with CPR. A defibrillator was applied but detected no shockable rhythm. Paramedic arrived at H3-15 at 17:35 hours. Return of spontaneous circulation was achieved but he remained unconscious and was taken to City Hospital, arriving at 18:16 hours. He remained very unwell and despite continued treatment died on 23 January 2021. Post-mortem examination confirmed there had been a sufficient period of reduced blood and oxygen supply to the brain, resulting in irreversible injury. It is known that when commissioned H3-15 was intended for infectious prisoners who needed to shower in isolation. The shower was decommissioned but the shower head was left in situ. It is unknown when or why it was decommissioned. In November 2017 H3-15 was taken out of use following damage to the cell, including damage to the dome mirror and the bed. In July 2020 H3-15 began to be used again without the mirror. No explanation was provided as to why. The 2020 cell risk assessment conducted by the mental health trust did not identify the disused shower head in H3-15. The process was non-standard and conducted over the telephone due to Covid-19 restrictions. Following a post-mortem the medical cause of death was confirmed as: 1a Hypoxic/Ischaemic encephalopathy 1b External neck compression 1c . The jury’s conclusion: Saifur Rahman died from hypoxic/ischaemic encephalopathy. Mr Rahman's intention when fashioning the was to commit suicide. There was a clear thought process in creating a which caused external neck compression which led to from his . Given his diagnosis of Bi-polar disorder with mixed affective state, he displayed impulsive behaviour and made rash decisions. This contributed to his intention in fashioning the . It was inappropriate to use H3-15, given it had a was not replaced after it had been damaged. The risk assessments conducted by the mental health trust were insufficiently recorded due to ineffective sampling methods, non-identification of cell differences and reliance on historical records. The prison weekly fabric checks conducted by custody managers were insufficiently recorded. 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. 5 The MATTERS OF CONCERN are as follows. – 1. Calling a “code blue”: the evidence revealed that the safety critical code blue call – automatically triggering an emergency response - was delayed by up to 2 minutes. The evidence was inconsistent on whether the cell entry briefing included the identification of an extra officer with a radio, and why therefore an officer in full person protective equipment ran out of the cell and across the ward to where she had left her radio to call the code blue. Delayed code blue calls have been a repeated problem at HMP Birmingham despite it being raised by the Prison and Probation Ombudsman and coroners in earlier regulation 28 reports. My ongoing concern is that delayed code blue calls will continue, and consideration should be given to the effectiveness of training in light of the evidence given by the prison officers at the inquest. 2. Cell history: the evidence revealed that cell fabric history - including fabric changes, damage and repairs - is safety critical information. Information about the history of cell H3-15 was lost or unclear as it transversed control of the prison changing from G4S to national control in 2018-2019 and there was no prison master/central record. My ongoing concern is that HMP Birmingham does not currently have a master/central record of cell history and relies on Amey who have a national contract for cell fabric changes and repairs. The evidence was unclear on whether the prison would have access to this safety critical information if the third party contractor changed. 3. NHS annual risk assessment: the evidence revealed that the mental health trust assessors had historically only dip-sampled a selection of the 15 x 2 cells on health care ward 2 (physical health) and ward 3 (mental health). They did not record which cells had been visually checked and relied in part on second- hand information from the prison about cell fabric and design. There had not been effective communication between the prison and health care staff. Generally, the trust had 140+ buildings across its entire estate to assess, this was done by two members of the health and safety team, and the assessment of the health care unit at HMP Birmingham was expected to be completed over several hours on one day. I was provided with a verbal undertaking that the trust would now visually inspect all 15 x 2 cells annually. However, this relies exclusively on the co-operation of the prison who have competing tensions given the operationally dynamic and challenging environment, especially if cells are occupied during the assessment. My ongoing concern is that there is no formalised process between the prison and mental health trust to visually inspect each cell. It is recognised prisoners housed on ward 2 and 3 are at a much greater risk of suicide than the general prison population, and general public as a whole, and will spend a great deal of time unobserved in the 15 x 2 cells. Therefore, in my view, visually inspecting 30 cells is not disproportionate to the level of risk and is not comparable to assessing an outpatient building in the community. The dynamic and challenging environment means it is likely all cells cannot be inspected on one visit. Visually inspecting each cell therefore needs to be properly planned and resourced by both the prison and mental health trust and consideration needs to be given to a formal process. 4. Prison risk assessment: the evidence revealed that dynamic daily and weekly prison officer cell fabric checks did not identify the risks with cell H3-15. The evidence from the mental health trust was that as their risk assessment is annual and the environment on ward 2 and ward 3 is dynamic and can quickly change, the prison needs to undertake its own risk assessment. I was provided with a verbal undertaking that the head of safer custody will undertake the first annual prison cell cells 6 months after the NHS risk assessment, and delegate twelve monthly thereafter, resulting in alternating 6 monthly risk assessments. My ongoing concern is that there is no formalised process and consideration needs to be given to how results of the prison acted upon, by the mental health trust. risk assessment visually inspecting all 15 x 2 risk assessment is communicated to, and 6 7 8 9 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21 July 2022. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following interested persons: (1) Mr Rahman’s family. (2) Prison and Probation Ombudsman. (3) West Midlands Police. I have also sent it to the following who may find it useful or of interest: (1) Care Quality Commission. (2) Prison Governor, HMP Birmingham. (3) INQUEST. 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. Date of report: 26/5/22 Mr James Bennett HM Area Coroner for Birmingham and Solihull
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.
26 May 2022
Legal Department
B1 – Unit 1
50 Summer Hill Road
Birmingham
B1 3RB
James Bennett
Area Coroner for Birmingham and Solihull
The Birmingham and Solihull Coroner’s Court
Steelhouse Lane
Birmingham
B4 6BJ
BY EMAIL ONLY
Our Ref: Rahman
Your Ref: 10375320 - Saifur RAHMAN (
)
Date:
20 June 2022
Dear Mr Bennett,
Re: Prevention of Future Deaths in the inquest of Saifur Rahman (deceased)
Thank you for sharing the Prevention of Future Death’s report with us on 26 May 2022.
Whilst we recognise the value of such reports and are committed to making improvements to
our service, we were disappointed to have received a report in respect of this inquest. As a
Trust we had gone to great lengths to provide evidence during the hearing that we had taken
lesson learning in respect of this inquest very seriously. We also evidenced that we had acted
on all the aspects that had been found in the Serious Incident Investigation and issues which
arose during the inquest itself, through both written and oral evidence.
NHS Annual Risk Assessment
The Trust had already identified the sampling of cells under the Ligature Risk Assessment as
an area for improvement and prior to the inquest had provided evidence that the assessment
model had already been updated to enable greater coverage of cells from year to year and to
generate an audit trail for those cells which had been viewed in previous years,
During the inquest on 15 May 2022 you had raised a query as to whether every cell could be
viewed each year. Previously this had not been considered to be proportionate partly due to
the number of settings the Trust is responsible for assessing (which are not limited to
outpatient settings and include a variety of mental health settings of varying levels of
security) but also because the Trust is reliant on the prison to grant access to each cell
which might not always be possible if, for example, the occupant is dysregulated or the cell
has been contaminated or soiled. However, on 15 May 2022 evidence was given on behalf
of the prison that they would in future ensure that Trust assessors would be granted access
to every cell over a 1-2 day period and that they would commit to overcoming any limitation
Customer Relations │ Mon – Fri, 8am – 6pm
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on accessing any particular cell. Having received this assurance the Trust were able to
reconsider the proportionality of the assessment and confirm to you that in future years the
Ligature Risk Assessment would view all cells provided that the prison provided access.
Your report states that the Trust had given this as a verbal undertaking at the inquest. In fact
the commitment to view every cell each year was provided in writing on 16 May 2022 by way
of a signed and sworn witness statement from the Trust’s Head of Health and Safety and
Regulatory Compliance who is directly responsible for the assessor team. The Trust had
considered the request in light of the evidence heard at the inquest and provided a written
assurance by the following day.
In order for this reassurance to be given, the Trust did consider future planning and resourcing
to ensure that this would be completed. This takes place each year and the risk assessments
for the prison are part of the Audit schedule for the Trust. In respect of formalising the process
with the prison, the Trust’s Head of Healthcare at HMP Birmingham has emailed the Local
delivery Board to ask that this matter is placed on the agenda for the meeting on 16 th June
2022. This will ensure that the process is formalised. Commissioners will also be present at
this meeting.
Prison Risk Assessment
I would like to draw your attention to the wording of the recommendation for the Prison on their
Risk Assessments. You have stated ‘My ongoing concern is that there is no formalised
process and consideration needs to be given to how results of the prison risk assessment is
communicated to, and acted upon, by the mental health trust.’
This gives us some concern as the wording suggests that the Trust has some element of
control or can take action on any Risk Assessment carried out by the Prison. It was agreed in
evidence at the inquest that any actions developed within Risk Assessments carried out by
either BSMHFT or the Prison, would need to be taken by the Prison and not BSMHFT, as the
Trust has no control to make any repairs or fabric upgrades within the prison. The prison are
ultimately responsible for any actions, although we also monitor these through regular
meetings with the prison. I would be grateful if you can make any necessary amendments to
this point as we consider it is misleading.
I would like to assure you that we have taken the findings of the Serious Incident report and
the Coroner’s inquest very seriously and indeed had taken action to act on these, prior to the
completion of the Inquest itself, as attested to in evidence.
If you require any further information at this time, please do not hesitate to contact us.
Yours sincerely,
Chief Executive
Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 20 July 2022 Mr James Bennett HM Area Coroner for Birmingham and Solihull Coroners Court Steelhouse Lane Birmingham B4 6BJ Dear Mr Bennett, Thank you for your Regulation 28 report of 26 May 2022, addressed to the Secretary of State for Justice and the Chief Executive of Birmingham and Solihull Mental Health Trust. I am responding on behalf of HMPPS as the Director General of Prisons. I know that you will share a copy of this response with Mr Rahman’s family, and I would first 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. You have expressed concerns around the calling of emergency codes, the recording of cell maintenance, and ligature risk assessments in cells. I will address these concerns in the order that they have been raised. Given the often traumatic circumstances in which staff are expected to call a medical emergency code, it is recognised that this issue is one that must be continually reinforced to ensure it is fully embedded and staff are able to respond effectively. At a local level, HMP Birmingham have undertaken a range of initiatives to maintain staff awareness of the procedures, including ‘pop-up’ safety talks run by the prison’s safety team which continue to be delivered during staff briefings, prominent signage that provides guidance, and the issuing of leaflets to all staff members. Additionally, the Governor has reviewed HMP Birmingham’s local medical emergency response code protocol to ensure that staff training is a central focus and that all staff have up to date training, including refresher training for all staff, which is currently in progress. At a national level new emergency response guides were issued to all prisons which set out the actions required of staff in a medical emergency, including all the circumstances listed in the PSI 03/2013 Medical Emergency Response Codes under which a medical emergency response code should be called. In 2021, all Prisons were also issued with a supply of emergency response pocket cards which were shared with staff. The cards provided an instant reminder of how to respond to a medical emergency. In March 2022, a further supply of the emergency response pocket cards were issued to Regional Group Safety Leads for them to share with their prisons. The findings of this inquest have also been shared with the national Safety team so that further consideration can be given to the points you have identified when national policy is next reviewed and revised. In relation to cell maintenance, a central record of cell fabric history has been implemented and all cell repairs and any changes to a cell being in or out of use is now recorded. The prison maintenance database, Planet FM, has also been updated and has the ability to print the full records for any cell and evidence that all required maintenance work is completed will be required before a cell is put a cell back into use. Cell maintenance is now also discussed weekly by the AMEY lead during the Governor’s morning briefing to ensure that prison staff are aware of any maintenance work that is in progress or completed in order to share any updates. Finally, you have queried the process for cell ligature risk assessments following evidence heard at the inquest. This process has since been reviewed internally and the introduction of a formalised process is currently underway with the Health and Safety team, in partnership with the NHS. The prison will be accountable for visiting the cell six months after the NHS assessment to confirm that any obvious ligature points are identified and minimised as best as possible. On a national level, HMPPS is undertaking a review of ligature-resistant cells, which will include an assessment of the cell standards and regular maintenance to ensure that they do not deviate from the required standard over time. Thank you again for bringing your concern to my attention. I trust that this response provides assurance that the appropriate action is being taken. Yours sincerely, Director General of Prisons
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