Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0204, written 1 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jul 2022 |
|---|---|
| Reference | 2022-0204 |
| Deceased | Dominic Noble |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (Eastern) |
| Category | Suicide (from 2015) · Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Practice Plus Group Health and Rehabilitation Services Limited 1 CORONER I am Kevin Mcloughlin, Senior Coroner, for the Coroner area of West Yorkshire (East) 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 24 August 2020 I commenced an investigation into the death of Dominic Robert Noble, aged 32. The investigation concluded at the end of the Inquest on 30 June 2022. The conclusion of the Inquest was a narrative conclusion based upon the cause of death of 1 a Hanging. The narrative conclusion was that Mr Noble died as a result of suicide and made findings in relation to his management and the healthcare provided to him whilst he was on remand in prison. 4 CIRCUMSTANCES OF THE DEATH Mr Noble was remanded to HMP Leeds on 8 June 2020 on terrorist charges. In the 10 weeks he was in prison he was seen on multiple occasions by the nursing staff. A decision was made on 14 July 2020 that he should be assessed by a psychiatrist but he remained on the waiting list without an appointment date at the time of his death on Saturday 15 August 2020. 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) Evidence was taken at the inquest that: (i) HMP Leeds has only 3 days per week of a psychiatrist's time available (ii) HMP Leeds has some 5000 prisoners arriving each year. (iii) A large proportion of the prisoners arriving have mental health issues (iv) The mental health team is mainly a nurse-led service (v) The division of labour between mental health nurses and psychiatrists is that a doctor is responsible for the diagnosis of mental illness, prescribing medication such as anti-psychotic drugs and seeing prisoners/patients with severe or complex conditions. Mental health nurses make initial assessments and provide ongoing care. (vi) Concern was expressed about the adequacy of the psychiatric doctor provision to provide psychiatric treatment for a large population which includes men with significant mental health issues. (vii) Mr Noble was deemed to require assessment by a psychiatrist on 14 July 2020 as a non-urgent case but at the time of his death on 15 August 2020 no appointment had been given. 1 (viii) A mental health nurse working on behalf of PPG on 10 July 2020 identified the 11 possibility of emerging psychotic features" and noted the sentiment that engaging in treatment as soon as possible militated in favour of a better outcome. Where such a suspicion was raised it would have been advantageous to obtain a second opinion from a psychiatrist swiftly (particularly after his mother contacted the prison to report his paranoid and bizarre conversation regarding a gun, a secret room in the prison and some unknown person trying to kill him.) (2) It is acknowledged that evidence was given at the inquest that: (i) PPG could draw additional psychiatric input from elsewhere in the PPG group, but there was no evidence to indicate when, if ever, this was last done. (ii) Waiting times for an appointment with a psychiatrist in the community could be 5 months or more and thus the principle of equivalence of care was achieved. (3) Concern was expressed in the course of the inquest that the meagre provision of psychiatric consultant availability might deter mental health nurses from making referrals. This concern was not accepted on behalf of PPG. Despite this the concern remains that a self-fulfilling prophecy has inadvertently been created in which referrals are not made because there is no resource to respond to any which may be made (4) The concerns raised mirrored issues raised in an inquest which concluded on 1 June 2022 relating to the death of Mohammed lrfaan Afzal in HM Prison Leeds on 4 August 2019. In a narrative conclusion the jury concluded that despite an urgent referral to a psychiatrist on 15 July 2019, no appointment had been provided before his death on 4 August 2019, "it is possible that the delays in providing treatment contributed more than minimally to Mr Afzal's death". (5) In view of these concerns PPG are asked to review the availability of psychiatrists at HMP Leeds to determine whether it is sufficient to meet the needs of a cohort of mentally unwell prisoners. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 1 September 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 report to the Chief Coroner and to the following Interested Persons , mother of the deceased • I have also sent it to: • • • • NHS England The Rt Hon Dominic Raab MP, Secretary of State for Justice The Rt Hon Sajid Javid MP, Secretary of State for Health and Social Care The Independent newspaper FAQ who may find it useful or of interest. 2 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 Kevin Mcloughlin Senior Coroner, West Yorkshire (East) 1 July 2022 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Practice Plus Group Hawker House 5-6 Napier Court Napier Road Reading Berkshire RG1 8BW HM Senior Coroner Mr K. McLoughlin West Yorkshire (Eastern District) Coroner’s Office and Court 21 Northgate Wakefield WF1 3BS 26 August 2022 Dear Sir Regulation 28: Prevention of Future Deaths Report - Dominic Noble I write in response to your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus Group on 1 July 2022 following the inquest touching upon the death of Mr Dominic Noble at HMP Leeds. Practice Plus Group would like to express its sincere condolences to Mr Noble’s family and friends. This response addresses the matters of concern in so far as they relate to Practice Plus Group Health & Rehabilitation Limited (“Practice Plus Group”), the lead provider of healthcare services at HMP Leeds since April 2016. Matter of Concern: The availability of psychiatrists at HMP Leeds and whether it is sufficient to meet the needs of a cohort of mentally unwell prisoners. Response: Current Provision At present the psychiatry provision with Healthcare at HMP Leeds is subcontracted to the Midlands Partnership NHS Foundation Trust (MPFT). They employ a locum psychiatrist to be present on site for 6 sessions per week across 3 days (Thursday, Saturday & Sunday). On Thursday mornings the psychiatrist has a clinic and in the afternoon he has protected time for multi-disciplinary team meetings and attendance at the multi-professional complex case clinic Practice Plus Group Health and Rehabilitation Services Ltd. Registered in England No 10498997 Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW (MPCCC). On a Saturday and Sunday he provides clinical sessions across the prison, this approach has proven to be effective over holding clinic in a dedicated room in reducing waiting lists and increasing engagement, based on a triaged list of patients who need to be assessed/reviewed. This is favourable in comparison to similar Category B remand prisons, e.g. HMP Doncaster and HMP Hewell, where there are currently fewer sessions. As in the community, Practice Plus Group delivers a stepped care model, which focuses on providing the most appropriate care for the concerns a patient may have. By adopting this model most people with mental health problems do not need to see a consultant psychiatrist. The stepped care model of mental health focuses on providing people with the right level of support from the right clinician at the right time. For example, people experiencing mild to moderate depression and anxiety would see a primary care mental health clinician in the community, alongside the GP, which is step 2/3. Patients experiencing severe depression, psychosis or more complex mental illness, would be seen by a mental health specialist working with a multidisciplinary team of professionals, including psychiatrists and psychologists alongside, for example, nurses, social workers, assistant psychologists and support workers. Most people in the community do not therefore see a psychiatrist as their needs are better met by nurses and therapists, leaving psychiatrists to focus on more severe and complex problems. The recently published NICE guidance for ‘Depression in adults: treatment and management’ recommends “Commissioner and providers of mental health services should consider using models such as stepped care or matched care for organising the delivery of care and treatment of people with depressions.” A copy of this guidance is enclosed for your information. Within HMP Leeds the psychiatrist is a part of a much larger mental health team which encompasses a clinical psychologist, two assistant psychologists, nine registered nurses including a learning disability nurse, a mental health practitioner who is a social worker, one senior support worker and a dedicated administrative assistant. Practice Plus Group also has the option to request additional support services from other prisons in the Yorkshire region should that be required. The prison mental health team covers a whole range of conditions which in the community would be addressed by both primary care services and secondary care services (specialist teams). They are an integrated team who carry out assessments and deliver interventions, and work Page 2 of 5 closely alongside the substance misuse team, recognising that people in prison often have multiple needs at the same time. Referral Avoidance We are not aware of any evidence that the current level of psychiatric resource is leading to the mental health team not escalating people who are severely mentally ill appropriately. At the inquest, Head of Healthcare, gave evidence that the mental health team’s approach remained that where there was doubt as to whether a referral should be made, it would be and was made. Our mental health nurses have been trained to independently assess patient needs and bring complex patients for discussion at the weekly multi-disciplinary team meetings. From these discussions, if the team believe that psychiatrist or psychologist input is required an appointment will be booked in accordance with the level of urgency identified. Substance misuse colleagues are also present in the integrated multi-disciplinary team meeting. Community Equivalence As outlined above, Practice Plus Group delivers a stepped care model in line with that which patients receive in the community. Like in the community, not all patients assessed will require contact with a psychiatrist, with 80% or more of patients in community with mental health issues being managed by their GP. Practice Plus Group’s current response times are measured against expectations set out in NHSE Service Specification: Integrated Mental Health Services in Prisons in England (2018). In July 2022 94.5% of urgent cases were seen within 48 hours and 69.9% of patients needing routine appointments assessed within 5 days. We believe this to be considerably more responsive than community services at present. As in the community, we use a dynamic approach to assessing individuals who present with complex risks, involving strong multi-disciplinary team working. There are clear embedded referral pathways and any patients identified as complex would be escalated to the psychiatrist. Page 3 of 5 Intended Changes Following the Learned Coroner’s comments during the inquest into the death of Mr Afzal, , Practice Plus Group’s Regional Director North – Health in Justice, began discussions with Commissioners at NHS England. Whilst Practice Plus Group maintains that the level of psychiatry provision is at least equivalent to that offered in the community, we also recognise that there are significant levels of mental health morbidity in prisons, particularly in a local remand setting such as HMP Leeds. The Learned Coroner’s comments and subsequent report have highlighted a potential need and we have therefore approached our Commissioners for additional resource. has discussed with NHS England the submission of a business case for greater psychology and psychiatry provision at HMP Leeds. NHS England, are in principle supportive of increasing the commission of psychology and psychiatry provision at HMP Leeds, but have asked for a West Yorkshire wide mental health service review to be undertaken before any additional investment is made. As budget decisions and funding is the remit of the Commissioners, it is within their gift to request such reviews before business cases are submitted. The review will start once the Regional Mental Health Lead has returned from annual leave. It is anticipated that this will take 2 weeks to carry out with the intention being that a business case is submitted to the Commissioners by the end of September. Once the business case has been submitted any decision as to additional resources is for NHS England, and a decision could take up to 12 months. HMP Leeds is a high demand remand site and we are seeking additional resource with the aim to improve the number of clinical sessions from 6 to 8 per week. In effect this means that HMP Leeds will need the equivalent of a half-time psychiatrist in addition to what is currently in place in order to achieve the additional clinical sessions. This is due to the non-patient facing time that all directly employed consultant psychiatrists working for Mental Health Trusts have in their contract. These activities include clinical administration tasks (e.g. letters and referrals), service development and training/development. Even should additional funding be agreed, it is important to highlight that this may not provide an immediate resolution. As is well documented, recruitment in the healthcare sector is currently very challenging, as evidenced by the widely reported vacancies across the NHS. In addition it is not easy to find clinicians who want to work in the custodial estate and it is particularly Page 4 of 5 challenging to recruit psychiatrists, who are currently in peak demand due to the increase of mental health issues as a result of the Covid pandemic. I hope that the above response provides assurance that Practice Plus Group are committed to providing a high quality healthcare service at HMP Leeds and trust this response addresses the concerns you had. I would like to end this response by taking the opportunity of inviting you to visit the healthcare team at HMP Leeds should you wish to discuss and review first-hand the services that PPG provide, as set out in this letter. Yours sincerely, National Medical Director, Health in Justice Practice Plus Group Enc. - Depression in adults: treatment and management (NG222), NICE guidance, published 29 June 2022 Page 5 of 5
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