Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0343, written 10 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Aug 2022 |
|---|---|
| Reference | 2022-0343 |
| Deceased | Allan Waddup |
| Coroner | Andrew Hetherington |
| Coroner area | North Northumberland and South Northumberland |
| Category | Suicide (from 2015) · State Custody 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.
ANDREW HETHERINGTON
H M Senior Coroner for North Northumberland and
Acting Senior Coronerfor South Northumberland
County Hall, Morpeth, Northumberland NE61 2EF
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Tees, Esk and Wear Valley, c/o Ward Hadaway LLP
1
CORONER
I am Andrew Hetherington, Senior Coroner for North Northumberland and Acting
Senior Coroner for South Northumberland.
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.
http://legislation.gov. u k/u kpga/2009125/schedule/5/paragraph /7
http://www.legislation.gov .uk/uksi/2013/1629/part/7 /made
3
INVESTIGATION and INQUEST
On 16 December 2019 I commenced an investigation into the death of Allan
Michael WADDUP. The investigation concluded at the end of the inquest . The
conclusion of the inquest was
Suicide
1a Pressure on the Neck
1b Hanging
1c
4 · CIRCUMSTANCES OF THE DEATH
The inquest heard that in the North East cluster of prisons Tees Esk & Wear
Valleys NHS Foundation Trust (TEWV) are subcontracted to provide secondary
mental health services who in turn subcontract primary mental healthcare
services to RETHINK. It was heard that once a referral is received into the mental
health team those referrals are triaged within 24 hours. Further that based on
contractual obligations, referrals must be triaged within 24 hours of receipt. The
triage is undertaken by a qualified mental health or learning disability nurse. The
outcome of the triage is that when assessment is deemed to be required the
patient is referred to primary care (Rethink) or secondary care {TEWV). I heard
that a routine as~essment should be offered within 4 working days after triage. I
did not hear any evidence that would suggest Mr Waddup's assessment was
deemed to be urgent. I heard that an urgent referral would take place urgently and
within 24 hours with the inmate being kept safe. Mr"Waddup was referred to the
mental health team at HMP Durham on 29th October 2019 following his recall to
prison. His needs were identified as anxiety and depression. He was triaged by a
mental health nurse on Thursday 30th October 2019 and was sent to RETHINK
for assessment. An assessment should have been offered within 4 working days
i.e. before Wednesday 6 November 2019. On 1st November 2019 Mr Waddup
was transferred to HMP Northumberland On 4 November2019 a HMP Durham a
psychological well-being practitioner noted the triage had been received by
RETHINK but the patient had been transferred. On 12th November 2019 a
telephone call handover was provided from primary care in HMP Durham to
primary care in HMP Northumberland. This was 13 days/7 working days after
triage. I heard the delay in assessment was due to the absence of a staff member.
On 14th, 19th and 21st November 2019 attempts were made to assess Mr
Waddup in his cell by telephone. The system in place in 2019 was that the day
before the appointment the wing are notified that an inmate has an appointment
with healthcare. It is unclear as to whether Mr Waddup would have been
personally aware of the appointment. He worked and would have left the wing at
specific times. On 21st November2019 on opt in letter and discharge letter was
issued via internal post by RETHINK. The letter requested he make contact by 29
November 2019 other wise it was assumed he longer required input from the
service. After three to four attempts to assess Mr Waddup via in cell telephone,
he was not contacted in person. MrWaddup was discharged without having been
assessed on 2 December 2019. A letter was provided during the course of the
inquest. The discharge letter was undated On 5th December 2019 Mr Waddup
self referred via the prison kiosk system saying "I need to see someone from
mental health as my head is gone and I'm really down and in a bad place right
now pis asap". 5th December2019 is a Thursday and the time that Mr Waddup
made that referral is not clear. The referral was received by the prison
administration team and added to the mental health teams triage waiting list on
9th December 2019 at 09.54 hours. The referral was triaged by a mental health
nurse and by a RETHINK colleague on 12 December 2019, 7 days after Mr
Waddup self-referred himself to mental health services. The mental health team
do not triage cases on a Saturday and mental health services are not contracted
to provide mental health services at weekends at HMP Northumberland. On 12
December 2019 a triage form was completed with the decision that the primary
care (RETHINK) should attempt to re-engage with Mr Waddup. Mr Waddup was
not assessed by primary mental healthcare prior to his death on 13 December
2019. Mr Waddup had a telephone call at 19.47 hours on 12 December 2019
where he received upsetting news. The contents of that telephone call and what
was discussed were not available to anyone working in the prison uritil after his
death
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 MATIERS
OF CONCERN are as follows. -
[BRIEF SUMMARY OF MATTERS OF
CONCERN] (1) MrWaddup was referred to mental health on 29th October2019
on triaged within 24 hours on 30th October 2019. Attempts were made to assess
him bv teleohone on 14, 19 and 21 November 2019. It is not clear if Mr Wadduo
personally knew of the appointments. Appointment letters are currently not sent
to inmates at HMP Northumberland to notify them of planned appointments.
Prisoners could be notified on the day via the appointment scheduling process
within the prison whereby the wing is notified of who has appointments with
various departments. I heard that TEWV provide mental health services across
the North East cluster of prisons including four prisons in the North West. In some
custodial facilities an appointment letter is sent. This system is not replicated in
HMP Northumberland (2) Mr Waddup was referred to mental health on 30
October 2019. Attempts were made to assess him in his cell over the telephone
on 14, 19 and 21 November 2019. He was discharged from mental health on 2
December 2019 without an assessment being undertaken. There was no in
person contact to explore the reasons he did not attend those appointments prior
to discharge. It could not be confirmed he was personally aware of those
appointments. He self-referred on 5 December 2019 and was not triaged within
24 hours or assessed prior to his death. An immediate review of the Did Not
Attend (DNA) policy for the mental health services to include an in person contact
is being undertaken prior to discharge but has not been completed. (3) Mr
Waddup self-referred via the kiosk system. There is no triaging of referrals on a
weekend. A disclaimer or warning directing inmates to how to seek urgent
assistance is not currently displayed on the kiosk.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by Tees Esk.& Wear Valleys NHS Foundation Trust. 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
exolain whv no action is orooosed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons The family of Mr Waddup, Sodexo Justice Services, G4S and Rethink. 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
1oth August 2022
Signed:/ (-4 1-\J/.:f", .,, "°',W
v-- II'
,
Andrew Hetherington HM Senior Coroner for North Northumberland and Acting
Senior Coroner for South Northumberland
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.
Trust Headquarters
West Park Hospital,
Edward Pease Way,
Darlington
DL2 2TS
Dear HM Coroner,
Re: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS REPORT regarding
HMP Northumberland following the Inquest into the death of Allan Waddup
Following a review of the Regulation 28 Report 19th August 2022, we have reviewed the
matters of concern to HM Coroner and wish to share the following feedback and actions.
Concern 1
(1) Mr Waddup was referred to mental health team at HMP Durham on 29th
October 2019 and triaged within 24 hours on 30th October 2019.Attempts were
made to assess Mr Waddup in his cell by telephone on 14, 19 and 21
November 2019. It is not clear if Mr Waddup personally knew of the
appointments. Appointment letters are not currently sent to inmates at HMP
Northumberland to notify them of planned appointments. Prisoners could be
notified on the day via the scheduling process within the prison whereby the
wing is notified of who has appointments with various departments. I heard that
TEWV provide mental health services across the North East cluster of prisons
four prisons in the North West. In some custodial facilities an appointment
letter is sent. This system is not replicated in HMP Northumberland.
Appointment letter templates have been reviewed and updated and have now been
introduced across all prison establishments, including HMP Northumberland where
TEWV provide Mental Health care delivery. As part of this process of review, the letter
content has been reviewed to ensure its content is succinct and clear, dated and
provides the relevant information.
The Transfer of care telephone handover call has been audited between HMP Durham
and HMP Northumberland to ensure patients are handed over in a timely manner. Audit
results show this process is effective and patients are handed over within the required
contractual timeframe of 24 hours or, the next working day if the transfer takes place at
the weekend. Any urgent transfer information is handed over on the day of the expected
transfer.
The standard process has been reviewed and updated to ensure all staff are clear
regarding responsibilities of transferring patient care. The templates the sending and
receiving clinicians fill out, to complete the handover, have been updated to improve
consistency and robust information sharing processes. Staff have received support in
completing the documents to ensure full awareness.
In order to ensure compliance with the required contractual timeframe for carrying out
assessments (4 working days if a non-urgent appointment), we have carried out an audit
of this process in HMP Northumberland and can confirm that the audit result
demonstrated 100% of offered assessments are undertaken within the 4 working days.
Concern 2
(2) Mr Waddup was referred to mental health on 30 October 2019. Attempts were
made to assess him in his cell over the telephone on 14, 19 and 21 November
2019. He was discharged from mental health on 2 December without an
assessment being undertaken. There was no in person contact to explore the
reasons he did not attend those appointments prior to discharge. It could not
be confirmed he was personally aware of those appointments. He self-referred
on 5 December 2019 and was not triaged within 24 hours or assessed prior to
his death. An immediate review of the Did Not Attend (DNA) policy for the
mental health services to include an in person contact is being undertaken
prior to discharge but has not been completed.
Following the inquest, an immediate lessons learned bulletin was shared with all staff
working across the service within the Trust, advising at the point of discharge,
appointments must take place face to face. A service level meeting was also convened to
share the information and requirements with Team Managers, to ensure information was
filtered down to all staff. The Operational Policy for the service has been updated to
reflect the updated discharge process and a request has been made to ensure upon
review (in January 2023) this is also reflected in the trust wide discharge policy.
Concern 3
(3) Mr Waddup self-referred via the kiosk system. There is no triaging of referrals
on a weekend. A disclaimer warning directing inmates how to seek urgent
assistance is not currently displayed on the kiosk.
The prison service provider at HMP Northumberland has granted the request to remove
the ability to refer to mental health services via kiosk. Due to the restrictions on the prison
kiosk system, men are unable to give any detailed rationale for the appointment request
making triage processes difficult for the team upon receipt of the request. A request has
been made to the prison provider at HMP Northumberland as to whether an electronic
referral can be uploaded to the kiosk system, as well as a notification advising patients
of timeframes for referrals to be processed and who to contact, and how, in an urgent
situation.
In the interim, posters have been produced and displayed on the wings providing clear
information to all prisoners about how to refer to the mental health team using a self-
referral, or by speaking to any member of staff. Posters include what to do in urgent or
crisis situations, specifically in relation to risk to self.
wh37130972v1
2
Self-referrals, including easy read versions, are available to all men on wing locations.
The referral asks specific questions which allow the team to triage the referral
appropriately in relation to service required, as well as urgency.
This is consistent with all other services within the NE cluster of prisons.
Yours sincerely
Executive Director of Nursing and Governance
wh37130972v1
3
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