Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0039, written 2 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Feb 2023 |
|---|---|
| Reference | 2023-0039 |
| Deceased | Jason Williams |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Alcohol, drug and medication related deaths · State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. 3. , Director General Operations His Majesty’s Prison and Probation Service (HMPPS) , Chief Executive of NHS England , Governor at HMP Guys Marsh, Shaftesbury, Dorset 1 CORONER 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 13th August 2020 an investigation was commenced into the death of Jason Anthony Williams, born on the 7th January 1981. The investigation concluded at the end of the Inquest on the 30th January 2023. The Medical Cause of Death was: 1a Synthetic cannabinoid intoxication The jury reached a narrative conclusion that “Jason deliberately took drugs but did not intend the consequences to be fatal i.e he had no intention to end his life” 4 CIRCUMSTANCES OF THE DEATH As recorded by the jury in Section 3 on the Record of Inquest: At 15.15 hours on the 31st July 2020 Jason Anthony Williams was found unresponsive in his cell, cell 42, Gwent wing, HMP Guys Marsh, Shaftesbury, by prison officers carrying out accommodation fabric check. His death was confirmed a short time later by attending paramedics. Prior to his death he had used psychoactive substances. On 30th July 2020 prison staff on the wing opened a welfare log following suspicion that Jason was under the influence of illicit substances, however the process set out in the Illicit Substances Welfare Document was not fully followed. It cannot be established that this had any causative or contributory bearing on Jason's death the following day. 1 On 31st July 2020 Jason's cell door was unlocked by prison staff at 14.14 hours however a welfare check was not conducted upon unlock. It cannot be established that this had any causative or contributory bearing on Jason's death. i JASON'S HISTORY OF MISUSE OF DRUGS Jason's history of misuse of drugs probably caused or contributed more than minimally to his death. Jason had a habitual drug habit that was documented on assessment on entering HMP Guys Marsh and throughout his custodial sentence. ii JASON'S VULNERABILITY We are satisfied that Jason's vulnerability possibly contributed to his death more than minimally. Jason's drug dependency in Prison contributed to his vulnerability due to his apparent willingness to take illicit substances. iii THE DRUG PREVENTION STRATEGIES IN THE PRISON IN JULY 2020 The restrictions imposed in July 2020 due to Covid, impacted the execution of the drug prevention strategy. This possibly contributed more than minimally to Jason's death. iv. THE MEASURES TAKEN BY THE PRISON FOLLOWING THE SUSPECTED THROWOVER ON 25TH JULY 2020 v THE STEPS TAKEN BY THE PRISON, AND/OR ISMS TO SAFEGUARD JASON FOLLOWING THE SUSPECTED THROWOVER ON 25TH JULY 2020 AND ONCE HE WAS FOUND TO BE UNDER THE INFLUENCE OF PS ON 30TH JULY 2020 No specific instruction was given to staff relating to Jason following the suspected throwover of illicit items and the increase of psychoactive substance incidents around this time. Nor were there any additional briefings to prison officers or notices distributed to prisoners. This possibly contributed more than minimally to Jason's death. This could be constituted as a safeguarding failure towards Jason from the steps taken by 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. During the Inquest evidence was heard that: i. There was a differing opinion between professionals including those from the healthcare, Integrated Substance Misuse Service (ISMS) and prison staff as to whether Jason was vulnerable. 2 Evidence was given that there is no national guidance either from HMPPS or the NHS on how to care for vulnerable prisoners in custody. It was confirmed that there is reference in certain documents such as PSI 64/2011 to vulnerability but no specific dedicated guidance on vulnerability. There is no definition of vulnerability, what to look out for regarding vulnerability, who may be deemed to be vulnerable or how to care for a vulnerable prisoner. Those serving sentences relating to sexual offending are often referred to as vulnerable prisoners, but there are other reasons for vulnerability and there is no targeted guidance to assist those working within the prison estate to care for these individuals. For example, evidence was given that at HMP Guys Marsh they are in the process of creating guidance for caring for those at risk of self-neglect as there is no national guidance on this issue. ii. Evidence was heard that the keyworker programme is a national programme for application in all prisons. Keyworker sessions are an essential part of a prisoner’s journey through their sentence and prison life. Evidence was given that there has been limited success nationally since it’s roll out which was believed to be in 2016/2017 and one of the reasons for this is resourcing. Evidence was given that at HMP Guys Marsh they struggle to deliver the keyworker programme and that it has not been delivered at the desired level for a long time. I have concerns therefore that the current system in place is not fit for purpose. iii. There is national guidance in PSI 23/2014, which relates to the Prison NOMIS system, around the recording case notes on the system. At paragraph 4.9 it states: All staff who have contact with an offender and who have access to Prison-NOMIS must update case notes on a regular basis. In the NOMIS case notes for Jason there did not appear to be regular entries from Prison staff. For example, between the entry on the 19th March 2020 and 7th June 2020 there was no record by prison staff who had contact with Jason on the wing. Whilst it is noted this was when the Covid 19 pandemic began, this was a time when there should have been increased monitoring and recording due to the fact activities were suspended and there was less general contact with prisoners from others outside the wing. Information was provided that Prison staff have access to PSI 23/2014, they are provided with the Prison Officers’ Guide produced by HMPPS and they are provided with training on record keeping at the Prison Officer Entry Level Training (POELT) training. There is no refresher training at HMP Guys Marsh on record keeping, or the importance of it other than to cover 3 information sharing. Evidence was given as to the importance of triangulation of communication and care between the prison, healthcare and ISMS staff. Healthcare and ISMS have access to the NOMIS records as well as the prion staff and this is therefore the key record for information sharing about a prisoner, their risks and vulnerabilities. iv. Governor notices can be sent to prison staff and prisoners to advise them of any matters, including when there are warnings to be given to prisoners. In the past at HMP Guys Marsh, Governor notices have been sent out when there has been a spike in psychoactive substance incidents. There was no Governor notice sent out between the 25th July 2020, when there was a suspected throw over of illicit items into the prison, and the 3rd August 2020. Over this period of 9 days there were 106 recorded psychoactive substance attacks which was described in evidence as an incredibly high number. Evidence was given that these notices are issued at the discretion of the Governor. 2. I have concerns with regard to the following: i. ii. iii. iv. There is a lack of specific and dedicated national guidance to prison and healthcare staff on how to define and care for vulnerable prisoners. I would request that consideration is given to producing national guidance on this, to also include guidance on addressing self-neglect. The current keyworker programme is not working as planned at HMP Guys Marsh and there was reference to this also being reflected nationally. I would request that consideration is given to a review being undertaken of the keyworker programme within the whole prison estate, and also specifically at HMP Guys Marsh. The quantity and quality of record keeping by prison staff at HMP Guys Marsh on NOMIS. I request that consideration is given to providing refresher training to prison staff on record keeping to cover the importance of records and their contents, and the required regularity of recording. A Governor notice was not issued in the time leading up to Jason’s death to prisoners or staff around the concerns regarding access to, and the impact of using, psychoactive substances. I request that consideration is given to a review being undertaken by HMP Guys Marsh as to when such notices should be issued, particularly in relation to increased risks to prisoners around drug use. 6 ACTION SHOULD BE TAKEN 4 In my opinion urgent 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, 30th March 2023. 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) GT Stewart Solicitors on behalf of Jason’s family (2) Government Legal Department on behalf of the Ministry of Justice (3) Hill Dickinson LLP on behalf of Practice Plus Group (4) EDP I am also under a duty to send the Chief Coroner a copy of your response. I have also provided copies to the following who I believe this report will be of interest to: (1) Hill Dickinson LLP on behalf of Oxleas NHS Foundation Trust (2) Hill Dickinson LLP on behalf of Change Life Grow 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 Signed 2nd February 2023 Rachael C Griffin 5
3 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.
HM Prison and Probation Service
HMP Guys Marsh
Shaftesbury
SP7 0AH
Mrs Rachael C Griffin
Senior Coroner for Dorset
Bournemouth Town Hall
Bournemouth
BH2 6DY
Dear Mrs Griffin,
19 April 2023
You have requested that I provide a response to a Regulation 28 report which you
issued following the inquest into the death of Jason Anthony Williams at HMP Guys
Marsh on 31 July 2020.
As you are aware on 11 April 2023,
, Director General Operations, on
behalf of His Majesty’s Prison and Probation Service (HMPPS), wrote to you providing
a response to the concerns you had raised in relation to the Prison Service. The
response sets out the action that is being taken locally at HMP Guys Marsh, such as
the introduction of a Buddy scheme, the writing of local guidance for those at risk of
self-neglect and the introduction of an assurance check to ensure there are regular
case note entries being made. It also provides information about the weekly multi-
disciplinary meeting (Restrict Supply Tasking Group) that discusses and shares
information regarding the drug ingress into the HMP Guys Marsh.
Yours sincerely
GOVERNOR
Director General Operations
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London
SW1H 9AJ
Rachael Clare Griffin
Senior Coroner for the Area of Dorset
HM Coroner’s Office
Town Hall
Bournemouth
BH1 6DY
11 April 2023
Dear Ms Griffin
Thank you for your Regulation 28 report of 2 February 2023, addressed to the Governor of
HMP Guys Marsh and the Chief Executive of NHS England. I am responding on behalf of
His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.
I know that you will share a copy of this response with Mr Williams 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 raised some concerns following evidence heard at the inquest, and I will address
each of these in turn.
Prison Service Instruction (PSI) 16/2015 is the national policy for ensuring that
establishments comply with their duty of care to all adult prisoners and young offenders.
The policy mandates that Governors ensure efforts are made to safeguard prisoners and
that all vulnerable adults at risk are supported and protected from harm and neglect.
As you are aware, all prisoners are potentially vulnerable, with individual health and care
needs requiring proper assessment and management, and it for this reason that we aim to
support them all through key work. Where we identify specific issues such as prisoners at
risk of self-harm, violence, or concerns around abuse or neglect, HMPPS manage these
through a range of processes such as the Assessment, Care in Custody Teamwork,
Challenge Support and Intervention Plan, and safeguarding processes as set out in PSI
16/2015.
We do, however, recognise the gap around specific guidance on self-neglect and the
HMPPS National Social Care Board – a partnership group, involving the Department of
Health and Social Care, NHS England and the Association of Directors of Adult Social
Services, alongside HMPPS policy and operational leads – is developing a workplan based
on seven agreed priorities, one of which is to improve safeguarding practice in prison and
approved premises.
The findings from your report will be used to inform the activities needed to deliver this
commitment. In the interim, HMPPS will issue a learning bulletin to remind staff of the
existing requirements to identify and refer prisoners for assessment who appear to be self-
neglecting, and describe the actions that staff can take to support prisoners in such
circumstances.
Locally, HMP Guys Marsh have recently introduced a Buddy (Peer Led Mentor) scheme to
provide support for complex and vulnerable prisoners. There are currently seven Buddies in
place, and the prison are working on increasing this number. You heard evidence during the
inquest that the prison, are in the process of creating local guidance for caring for those at
risk of self-neglect. I wish to assure you the prison is working in collaboration with
healthcare to ensure this is published as soon as possible.
Key work is the foundation that supports prison safety by building relationships, and
promoting opportunities for rehabilitation. While the Covid pandemic and staffing pressures
have had a particularly negative impact on the key worker scheme across the prison estate,
we are committed to ensuring that key work is fully reinstated across the male closed
estate. With this in mind, the national Offender Management in Custody (OMiC) team will
use evidence, data and learning to review and develop the current key work model to
maximise the opportunity to deliver better outcomes directly associated with safety and
reducing reoffending. This will include reviewing key work and OMiC sentence
management, exploring ways in which the current delivery model can be made more flexible
to better support delivery, taking into consideration different prison functions and prisoner
cohorts.
All prison officers and staff receive an initial course of NOMIS training that includes the
importance of record keeping. While staff do not undertake refresher training on the use of
NOMIS, staff have received guidance on the new Digital Prison Service (DPS) reporting tool
which allows easier access to record keeping. In addition to this, the safety team at HMP
Guys Marsh have introduced an assurance check that ensures all prisoners have a case
note recorded on DPS weekly. Those prisoners who have been identified as isolating,
showing signs of self-neglect, or have identified social care needs must have a daily entry
inputted.
In respect of your last concern, HMP Guys Marsh have introduced a new weekly meeting
(Restrict Supply Tasking Group) which is attended by a multi-disciplinary team. The
purpose of this meeting is to discuss and share information regarding the drug ingress into
the prison, and to identify any specific strains and substances that are potentially
dangerous. If the risks identified require further action, a Governor’s Notice To Staff and a
prisoners’ notice highlighting the risks and concerns will be issued. Further to this, known
prolific substance misuse users will be issued with harm minimisation guidance and
support.
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 you raised.
Director General Operations
Ms Rachael Clare Griffin Senior Coroner for the Area of Dorset HM Coroner’s Office Town Hall Bournemouth BH1 6DY National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 08 June 2023 Dear Ms Griffin, Re: Regulation 28 Report to Prevent Future Deaths – Jason Anthony Williams who died on 31 July 2020. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 02 February 2023 concerning the death of Jason Anthony Williams on 31 July 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Williams’ family and loved ones. NHS England is keen to assure the family and the coroner that the concerns raised about Mr Williams’ care have been listened to and reflected upon. NHS England is the responsible organisation for the commissioning of healthcare into prisons, which is devolved to regional teams. Commissioning healthcare in prisons is done on a principle of equivalence, which has been defined by the Royal College of General Practitioners (RCGP) and broadly states that the aim is to ensure people detained in prisons in England, are offered provision of and access to appropriate services and treatment, considered to be at least consistent in range and quality, with that available in the wider community. I note that you have also sent your Report to His Majesty’s Prison and Probation Service and (HMPPS) and HMP Guys Marsh, who are better placed to comment on many of the concerns raised in your Report. All prisoners have the potential to be vulnerable, requiring a case-by-case assessment and careful management and in my response, I have considered the concerns raised in your Report regarding the apparent lack of national guidance on how to define vulnerability and care for and safeguard vulnerable prisoners. You highlight in your Report that evidence was given regarding HMP Guys Marsh, where guidance is under development for caring for those specifically considered at risk of self-neglect. Self-neglect is an extreme lack of self-care and covers a wide range of behaviours. It can be intentional, or unintentional in the case of someone living with a condition such as dementia or, can be caused or associated with mental illness or substance abuse. The Care Act (2014) statutory guidance includes self-neglect as a category falling under adult safeguarding, and a cause to make a safeguarding referral. Locally, adult safeguarding Boards and teams record indicators of self-neglect and NHS England includes information about self-neglect in a Safeguarding Adults Pocket Guide. More recently in late 2022, in conjunction with His Majesty’s Prison and Probation Service (HMPPS) and supported by Health Education England (HEE), NHS England developed and produced a training programme for Adult Safeguarding in a Secure and Detained Setting focusing on adult safeguarding and the roles and responsibilities of those working in secure and detained settings in England. The programme was designed for a multi-agency audience, to enable better collaboration between teams and create a culture of safety by embedding safeguarding into everything a prison does. NHS England is also working with the HMPPS National Social Care Partnership Board workplan which includes and action to improve safeguarding in establishments. I hope this reassures you that there is guidance in place to support all staff to be able to identify vulnerabilities in patients’ and take appropriate action to safeguard those patients and that there is further work planned to ensure a culture of safety and effective safeguarding is in place. In terms of the use of psychoactive substances, which was also a factor in this case, the Ministry of Justice (MOJ) ‘New Psychoactive Substances (NPS) Toolkit’ supports both custody and healthcare staff to manage the challenges around NPS use in secure environments, including prisons, and gives attention to particular challenges for healthcare staff. The full toolkit is available at NPS Toolkit. Thank you for bringing this important issue to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director
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