Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0184, written 20 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jun 2022 |
|---|---|
| Reference | 2022-0184 |
| Deceased | Khalid Abiaz |
| Coroner | Kirsten Heaven |
| Coroner area | Manchester 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.
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:
The Governor of HMP Swansea, 200 Oystermouth R·oad, Swansea
The Ministry of Justice, 102 Petty France, London , SW1 H9AJ
The Chief Executive of Swansea Bay University Health Board, 1 Talbot Gateway,
Bag Ian Energy Park, Baglan, Port Talbot SA 12 ?BR
1
CORONER
I am Kirsten Heaven, Assistant Coroner, for the coroner area of SWANSEA NEATH &
PORT TALBOT
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 13th September 2016 an investigation was commenced into the death of Khalid
Abiaz, a prisoner at HMP Swansea who died in his cell on 13th September 2016 after
having tied a ligature around his neck. He was 40 years of age at the time of his death.
The investigation concluded at the end of the inquest on 16th June 2022.
The medical cause of death was:
1a pressure on neck (hanging)
The conclusion of the inquest was as follows:
An excessively elongated immigration process lasting 17 years has led to a significant
amplification of Khalid's well documented mental health and housing issues. This cycle
of a lack of adequate housing to keep him safe and erratically prescribed medication
would have had a negative effect on his mental health. At times where risks by agencies
involved were identified there was a failure to ensure that Khalid had the relevant
medication and housing to keep him safe. There was a systemic failure to consider
historic assessment about his mental health; rather agencies focussed on current
presentation with apparent disregard and curiosity about historical data. Khalid led a
chaotic life and had a history of drug and substance use and had multiple contacts with
Government agencies .. Khalid had demonstrated on many occasions threats to self
harm and harm others which were well document on Government systems. An
unsympathetic and desensitised penal system with inadequate access to this data held
by relevant agencies and poor processes to ensure this data is reviewed and actioned
probably led to a situation in prison of Khalid having the opportunity to take his own life.
Khalid was at risk of suicide upon arrival at prison; the prison and nursing staff followed
an inadequate process without proper consideration and communication of all relevant
documentation and historical data that would have oresented additional information and
1
enabled the risk to be further considered.
suicide
4
CIRCUMSTANCES OF THE DEATH
The deceased was Khalid Abiaz
it is our belief that he intended to commit
Khalid was a Somalian asylum seeker with an outstanding asylum appeal who on
release from immigration detention in July 2016 experienced homelessness and three
attempts to take his own life following which he was detained on each occasion under
s.2 of the Mental Health Act 1983 (MHA). Khalid had a long history of mental health
issues and had been assessed on 3rd August 2016 by a consultant psychiatrist as
posing a significant risk to himself and others. On 8th September 2016, following a threat
to kill himself
medical clinic in Cardiff, Khalid was detained by South Wales Police ('SWP') under
s.136 MHA and assessed under s.2 MHA at University Hospital Llandough. Khalid was
not considered as meeting the criteria for detention under s.2 MHA and so was released
with no medication. On 10th September 2016 Khalid was arrested and charged by SWP
in respect of the incident on the 8th September 2016. He was then remanded into
custody and sent to HMP Swansea on 12th September 2016 with warning markers on
his prison escort record for threats of suicide and self-reported mental health issues. An
ACCT was not opened in reception and Khalid was found suspended in HMP Swansea
by a ligature in the early hours of 13th September 2016.
in the context of trying to get prescribed medication at a
5
CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to a 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 make a report under paragraph 7, Schedule 5 of
the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013
The MATTERS OF CONCERN are as follows:
1.
I heard evidence that following a review in 2015 changes to the ACCT document
and process were piloted in 10 establishments in 2019 and this included HMP
Swansea. As a result a revised ACCT version 6 and accompanying policy
guidance was issued. This revised guidance makes clear that an ACCT must be
opened by any member of staff who receives information that indicates a
prisoner may be currently at risk of self-harm or suicide and that this information
may come from a prison escort. However, this requirement is not new. It was
clear in my view from the HMP Swansea Suicide and Prevention Policy that was
in place at the time of Khalid's death that a warning marker for suicide on a
prison escort record ('PER') should result in the opening of an ACCT. The
prison officer who saw Khalid first in reception gave evidence that he was an
experienced prison officer with over 20 years-experience of working in prisons
including 18 years at HMP Swansea. At the time when Khalid came
into custody he was an ACCT assessor and remains in this role. He saw
Khalid's PER which stated that Khalid had recently made threats to kill himself
and was alleging mental health issues and he saw the NOEMIS transfer report
which contained reference to historic ACCTs that Khalid had been on in custody
and an act of cutting and ligaturing by Khalid 9 months before in December
2015. He did not open an ACCT but referred to the nurse who also did not open
an ACCT. In his evidence the Prison Officer stated that if a prisoner came into
custody now in 2022 with a warning on his PER stating that he has recently
made threats to kill himself then this would not be enough to trigger the opening
of an ACCT. This view is inconsistent with the mandatory revised ACCT policy
quidance that I have set out above. This indicates that the system for trainina on
2
2.
ACCT in HMP Swansea is inadequate. The Prison Officer could not recall
whether his ACCT training was up to date. His training records show that he
was ACCT trained in 2005, 2008, 2011 and 2014 and I am told there was
training on the new ACCT document that is not recorded in the training records
and a further up-skilling session with staff date not specified. I did hear that
training was difficult during the Covid 19 pandemic in HMP Swansea, however,
ACCT training is required to be carried out with much more frequency than the
training provided to the officer on reception and staff should understand the
warning markers that require an ACCT to be opened. I am concerned that
unless prison officers are provided with frequent ACCT training which is kept up
to date then there remains a risk of similar deaths occurring in the future in HMP
Swansea.
I heard evidence from the nurse who saw Khalid on reception. This person is an
experienced mental health nurse who is now a charge nurse on bank. The nurse
told me that he still does at times work through the bank as a mental health
nurse in HMP Swansea. At the time of Khalid's death the Nurse was the mental
health nurse working on reception and he completed the first reception health
screen for Khalid and he did not open an ACCT. It was unclear what documents
the nurse had seen on reception for Khalid but he did not asked prison staff if he
could see any documents. The Nurse gave evidence that even if he had known
that there was a suicide warning marker on Khalid's prison escort record this
would not have been enough combined with what Khalid said to him to open an
ACCT, he relies on Khalid's presentation. Khalid had been assessed by a
consultant psychiatrist as a significant risk to himself a matter of weeks before
he was seen by the Nurse in reception. HMP Swansea prison staff and the
Nurse were not aware of this information but even if the Nurse had known this
information his evidence was that this would not necessarily have been enough
for him to open an ACCT, he would consider presentation. The revised ACCT
version 6 and accompanying policy guidance set out above makes clear that an
ACCT must be opened by any member of staff who receives information that
indicates a prisoner may be currently at risk of self-harm or suicide and that this
information may come from a prison escort. The answers of the Nurse raise a
concern around the level and adequacy of the training on ACCT. The Nurse
stated that he has reflected on his practice but that he still places emphasis on
what the prisoner says and how they present when considering whether to open
an ACCT. I heard evidence that bank nurses were supervised in the prison but
that training on ACCT remained the responsibility of HMP Swansea. I am
concerned that a bank nurse may not receive access to ACCT training including
at the required regularity and I am concerned that unless this happens there
remains a risk of similar deaths occurring in the future in HMP Swansea
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 15 August 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.
8
COPIES and PUBLICATION
I have sent a copy of my reoort to the Chief Coroner and to the followina Interested
3
Persons, The Home Office, Cardiff and Vale University Health Board, Ministry of Justice,
South Wales Police, Swansea Bay University Health Board
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
20 JUNE 2022 ...... ... .......... .. ..... ... ..... . ... ... ... ... ... .
4
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.
Ms Kirsten Heaven
HM Assistant Coroner
The Guidhall
Swansea
SA1 4PE
15 August 2022
Dear / Annwyl Ms Heaven,
Director General of Probation, Wales and Youth
HM Prison and Probation Service
3rd Floor Churchill House
Churchill Way
Cardiff CF10 2HH
e-mail:
Thank you for your Regulation 28 report of 20 June 2022 addressed to the Ministry of Justice and the
Governor of HMP Swansea, following the inquest into the death of Khalid Abiaz on the 13 September
2016. I am responding as Director General of Probation, Wales and Youth.
I know that you will share a copy of this response with Mr Abiaz’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.
Following evidence heard at the inquest, you expressed concerns regarding prison and healthcare
staff understanding of their responsibilities within the Assessment Care in Custody and Teamwork
(ACCT) process, and the training provided to them. Thank you for bringing these concerns to my
attention.
I understand that a response is also being provided by Swansea Bay University Health Board, the
healthcare provider at HMP Swansea, so in relation to your concerns about healthcare staff I have
limited my comments to explaining the training that HMPPS makes available to our partners.
As you note in your report, in July 2021 ACCT version 6 (v6) was rolled out across the prison estate.
The revised form and guidance are intended to assist staff in providing high quality multidisciplinary
care and support to individuals at risk of suicide and self-harm. Training materials and presentations
have been produced and delivered across the estate in order to support staff in their understanding
and delivery of the ACCT v6 process. This includes risk identification and how best to provide support
to individuals.
Our policy (Prison Service Instruction 64/2011 Safer Custody) is clear that all staff who have contact
with prisoners must undertake training on ACCT, and that refresher training must be provided
according to local needs. This training forms part of the initial training undertaken by all Prison
Officers. A new version of the training, which includes information about ACCT v6, has recently been
produced and a programme is in place to ensure that all staff at HMP Swansea attend this as
refresher training by November 2024. In the light of your report, the individuals about whom you have
expressed specific concerns will be prioritised for this training, and for an upskilling session
specifically related to ACCT v6 that has also been made available by the national Safety Team.
In order to improve the identification of risk in new prisoners and to build confidence in decision
making around the opening of ACCT documents, fifteen members of staff who predominantly work in
the reception area, induction wing, and healthcare received the new training module in July 2022. The
Governor has issued guidance on risk identification and the establishment is scheduling additional
training focusing on risks, triggers and protective factors for staff working in these key areas.
At national level, the ACCT case co-ordinator training has also been refreshed with the expectation
that all previously trained staff will access the new training within three years.
HMPPS is committed to making ACCT training available to staff working for our partner organisations.
At HMP Swansea, healthcare staff are encouraged to access all suicide and self-harm prevention
training delivered within the establishment and the new modules will continue to be offered to them.
The Governor has also formally requested through the Head of Healthcare, that bank nurses are not
deployed in the reception area of the prison and are instead utilised in other areas within the
establishment. This is to ensure that permanent nursing staff who have undertaken the ACCT training
are allocated to the reception area to complete initial screenings.
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 / Yn gywir
Director General of Probation, Wales and Youth, HM Prison and Probation Service
Cyfarwyddwr Cyffredinol Prawf, Cymru ac Ieuenctid, Gwasanaeth Carchardai a Phrawf EM
Cadeirydd / Chair: Prif Weithredwr/Chief Executive: gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Swansea Bay University Health Board Headquarters Rydym yn croesawu gohebiaeth yn y Gymraeg ac yn y Saesneg. We welcome correspondence in Welsh or English. Your ref/Eich Cyf: Our Ref/Ein Cyf: 763 SBU Health Board Headquarters One Port Talbot Gateway, Seaway Parade Port Talbot SA12 7BR Date 15th August 2022 Mrs Kirsten Heaven, Assistant Coroner for Swansea and Neath Port Talbot, The Guildhall, Swansea, SA1 4PE Dear Mrs Heaven, Re: Inquest of Khalid Abiaz I write further to your correspondence regarding the above and the Prevention of Future Deaths Report (Regulation 28) notification issued to the Health Board on 20th June 2022. The Report was issued as a result of the inquest into Mr Abiaz’s death at HMP Swansea on 13th September 2016, which concluded on 16th June 2022. You detail your concerns in respect of the bank nurse witness, who was employed by Swansea Bay University Health Board (SBUHB). The bank nurse at the time of Mr Abiaz’s death was employed by Bro Morgannwg University Health Board and undertook the first reception screening for Mr Abiaz when he arrived at HMP Swansea. The report highlights your concern around the level and adequacy of the training on ACCT, which falls under the remit of the prison and thus will be addressed separately in the prisons response, but also concerns in respect of a bank nurse employed by SBUHB having access to the ACCT training. Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board Although the response from the Prison will address the majority of the points you raise in respect of the adequacy of ACCT training, the Health Board has been working closely with the Prison and we are able to confirm that two slots per ACCT training session will be ring fenced going forward for Health Board staff. Furthermore, Health Staff will be rostered to attend the ACCT Awareness training as a matter of priority. Updates on training numbers will be provided by the Health Care lead on a monthly basis via the Quality and Safety forum. Training will be a part of the mandatory induction for new Prison Health Board staff, and refresher training will be accessible to staff also, as and when the prison release dates. In addition, the Health Board and HMP Swansea have agreed that Health Board bank staff will no longer undertake the reception or screening function unless they are key trained, have the necessary clearances and have undergone the appropriate training. The substantive prison staff will be detailed to undertake the reception functions. To date, 8 prison health staff have undergone the version 6 ACCT training with 22 staff members remaining. The Health Board are also negotiating securing places for the medical staff on the training. This remains very much on our radar and as the national ACCT training dates are released, securing places will be a priority for the Health Board for those individuals who work in this setting. I trust that the details included in this response sufficiently address the matters of concern raised in the report and provide you with the required level of assurance. Please do not hesitate to contact us should you require any further information. Yours Sincerely, Chief Executive Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board
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