Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0094, written 15 Mar 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Mar 2023 |
|---|---|
| Reference | 2023-0094 |
| Deceased | Jai Singh |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | Suicide (from 2015) · State Custody related deaths |
| Organisation named | Birmingham and Solihull Mental Health NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Birmingham and Solihull Mental Health Foundation
Trust, NHS England (Health and Justice), and the Phoenix Partnership (Leeds) Ltd.
CORONER
I am Emma Brown, 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 1 February 2022 I commenced an investigation into the death of Jai SINGH. The investigation
concluded at the end of the inquest on the 10th March 2023. The conclusion of the jury at the
inquest was;
Suicide
The following matters probably caused or contributed to Mr Singh's death:
* The failings of safer custody to appropriately communicate and document family concerns to
other staff within the prison.
* The failure to use interpretation services to effectively communicate with Mr Singh by both the
custodial and the healthcare teams.
* The failure to communicate relevant information within and between the custodial team and the
healthcare team
* The failings to appropriately open, re-open and carry out the ACCT process.
* The failure to carry out sufficient and thorough welfare checks.
* That Mr Singh did not undergo an assessment for section 48 transfer.
* A significant lack of rigor in respect to the completion of official prison and healthcare
documentation.
* That Mr Singh was not admitted to ward 2 and remained on a residential wing.
The following matters possibly caused or contributed to Mr Singh's death:
* Failings to heed and communicate family concerns by both the custodial team and the healthcare
team.
* The failure to allocate an individual community psychiatric nurse as a single point of contact
following the opening of an ACCT.
CIRCUMSTANCES OF THE DEATH
Jai Singh died at City Hospital on the 28th January 2022 having been admitted after he
was found in cardiac arrest in his cell at HMP Birmingham on the 27th January 2022. Mr.
Singh had asphyxiated due to placing a bag over his head. He received CPR from prison
staff and paramedics and was resuscitated but had suffered irreparable brain and organ
damage.
Mr. Singh had been detained at HMP Birmingham on the 21st September 2021 whilst on
remand awaiting trial for the murder of his wife. From the time of his admission Mr. Singh’s
family were concerned that he was suffering from a severe mental health condition and
raised this in numerous emails and telephone calls to safer custody. The content of calls
and emails was not recorded on NOMIS casenotes for the information of the custodial
team and was not consistently communicated to the mental health team. The information
that was passed to the mental health team was not clearly recorded in the SystemOne
journal for all clinicians to see. Consequently, the opportunity to identify risk and open an
ACCT document was missed.
From an early stage Mr. Singh was reporting psychotic behaviour to community
psychiatric nurses and was noted to be behaving unusually by custodial staff but he
denied any active suicidal or self-harming thoughts. His cellmate and a Chaplain raised
concerns about his behaviour but still an ACCT book was not opened.
On the 22nd November 2021 an ACCT book was opened after Mr. Singh reported wanting
to kill himself. The ACCT assessment, reviews and care plan were deficient leading to the
ACCT being closed prematurely on the 30th November 2021. The post closure process
was also inadequate. During the time Mr. Singh was at HMP Birmingham he had a
number of welfare checks due to family concerns but these were superficial and
perfunctory and never carried out with an interpreter even though Mr. Singh's English was
poor. Consequently, his risk was not adequately assessed.
Following an assessment on the 3rd December 2021 a Consultant Forensic Psychiatrist
instructed by Mr. Singh’s criminal defence team identified that Mr. Singh was suffering
with auditory hallucinations, low mood, tiredness and suicidal ideation and made a
diagnosis of schizophrenia with an effective element. The Psychiatrist made a referral to a
secure inpatient unit, The Hatherton Centre, for a transfer under section 48 of the Mental
Health Act. The referral was sent to the Hatherton Centre but was not sent to HMP
Birmingham straightaway. The referral to the secure unit was not accepted because it was
made by an independent psychiatrist rather than the prison's mental health team. The
mental health team at HMP Birmingham were, however, contacted on the 13th December
2021 by a psychiatrist from the Hatherton Centre who stated that there had been a
request for assessment for transfer and asked for further information. He was given
misleading information that Mr. Singh was "coping well" and therefore informed the mental
health team that an assessment would not be carried out. No note was made of the
conversation with the Hatherton Centre psychiatrist and no action was taken to investigate
and pursue a section 48 transfer. The information provided by the independent Consultant
Forensic Psychiatrist and the history of psychotic symptoms in SystemOne records ought
to have resulted in an assessment by the Hatherton Centre. An assessment would have
been likely to result in section 48 transfer. Whilst Mr. Singh remained at HMP Birmingham
awaiting transfer he ought to have been under the care of the mental health team and
housed on ward 2 (the mental health inpatient wing).
Mr. Singh continued to report that he was hearing voices, hallucinating, struggling to sleep
and low in mood. He was reviewed by GPs at the prison on the 29th November, 13th
December, 4th January and 25th January who prescribed antidepressants and sleeping
medication which Mr. Singh reported were not working.
On the 14th January 2022 a prison Consultant Psychiatrist determined that Jai Singh
required urgent admission to the inpatient psychiatric ward for assessment. However, the
admission was not facilitated and Mr. Singh remained on a residential wing. The decision
not to admit Mr. Singh to the ward was not recorded in his SystemOne records. Mr. Singh
received no further input or support from the mental health team. When he was seen by a
GP on the 25th January 2022 it was identified that medication was not helping and Mr.
Singh needed to be seen by a psychiatrist but the GP thought he was going to be
transferred to Ward 2 and therefore took no further action.
All actions taken following Mr. Singh being found in cardiac arrest on the 27th January 2022 were
appropriate.
Following a post mortem the medical cause of death was determined to be:
1a Hypoxic-ischaemic brain damage
1b Multi-organ failure
1c Cardio-Pulmonary arrest due to asphyxia
II
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. A multitude of factors contributed to Mr. Singh's death across the custodial and
healthcare teams within HMP Birmingham. Many steps have been taken by all
organisations with responsibility for Mr. Singh's safety and health during his time at
HMP Birmingham to rectify failings that have been identified such as the consistent
failure to use interpreters, poor communication and record keeping within and
between teams, the absence of meaningful engagement with Mr. Singh's family,
insufficient consideration of family concerns and failings in the use of the ACCT
system.
2. Much of the evidence at the inquest focused on the central issue of repeated
missed opportunities to identify that Mr. Singh required admission to the prison's
inpatient ward, ward 2, and assessment for section 48 transfer to a medium secure
unit (which would have been likely to result in transfer to a medium secure unit).
The consequences of the failure to transfer Mr. Singh to an inpatient setting were
compounded by the fact that he was not taken onto the mental health team's
caseload promptly and therefore did not have the benefit of an allocated CPN and
the oversight and input of a mental health multi-disciplinary team. Many steps have
been undertaken by Birmingham and Solihull Mental Health Trust (who provide
mental health services within the prison) to minimise the risk of such a situation
occurring again.
3. However, there are two features of the mental health care provided to Mr. Singh
that create a risk to the lives of others that have not yet been rectified:
i. the fact that the mental health team multi-disciplinary team (MDT) does not
include a psychiatrist; and
ii. the absence of any ongoing risk assessment documentation for patients with
mental illness within the SystemOne records at HMP Birmingham.
4. In Mr. Singh's case it is my conclusion that it is likely that if a psychiatrist had been
at a mental health MDT meeting held on the 19th January 2022 they would have
identified that he needed to be admitted to ward 2 without further delay. At the very
least the need for urgent review by a psychiatrist and CPN would have been
recognised and facilitated which would in turn have led to admission. CPNs in Mr.
Singh's case continually failed to identify the significance of repeatedly and
consistently reported psychotic symptoms and consequently he did not receive
adequate assessment and treatment which increased his risk of self harm and
suicide which in turn was not sufficiently identified. The absence of a psychiatrist at
the MDT creates a risk that the significance of some symptoms and presentations
will not be recognised and further deaths could occur due to lack of appropriate
assessment and treatment.
5. Other electronic health care records systems used in mental health settings have a
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rolling risk assessment document that clinicians are required to review and update
at certain points in a patient's management. The risk assessment document
provides a prompt to clinicians to formally consider risk and come to a reasoned,
documented conclusion that then feeds into decision making. The record also
provides a reliable, easily accessible source of risk history. No such facility is in use
on SystemOne at HMP Birmingham. Further, the evidence given was that such a
system is not being used routinely across mental health care within the prison
estate and is not provided as standard on SystemOne. This creates an ongoing risk
to life arising from under-estimation of risk as a result of clinicians not formally
considering and assessing current risk levels, and salient risk history not being
easily accessible. It is understood by Birmingham and Solihull Mental Health Trust
that it should be possible to create a specific risk assessment record within
SystemOne and this is being considered locally. However, the evidence given was
that this issue should be highlighted nationally and that the developers and
distributors of SystemOne should be involved so as to ensure the best available
solution is identified.
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
11 May 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
1) The sisters of Jai Singh,
2) Children of Jai Singh,
3) Ministry of Justice (MOJ)
4) Birmingham Community Health Care (‘BCHC’)
5) Birmingham and Solihull Mental Health Foundation Trust (‘BSMHT’)
6) Prisons and Probation Ombudsman (‘PPO’)
7) Midlands Partnership NHS Foundation Trust (‘MPFT’)
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.
15 March 2023
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Signature:
Emma Brown
Area Coroner for Birmingham and Solihull
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.
Head Office
Uffculme Centre
52 Queensbridge Road
Birmingham
B13 8QY
Date:
26 April 2023
Mrs Emma Brown
Area Coroner for Birmingham and Solihull,
Steelhouse Lane,
BIRMINGHAM
B4 6BJ
Dear Mrs Brown,
RE: Prevention of Future Deaths Report for Jai Singh Puni (deceased)
Further to the Prevention of Future deaths report dated 15 March 2023, the Trust has now had
an opportunity to review the Matters of Concern raised. I would like to begin by offering my
sincere condolences to the family of Mr Puni for his very sad loss. As a Trust we have taken
your concerns very seriously and have aimed to act on these issues as quickly as possible to
ensure lessons are learned to benefit other patients in the future. I will respond to each issue
in turn.
1. The mental health team multi-disciplinary team (MDT) does not include a
psychiatrist.
The Trust has begun a 3 month pilot which will ensure a Consultant Psychiatrist attends the
MDT meetings at the Prison each week. The Secure Care and Offender Health Clinical
Governance Committee (CGC) will review the outcomes for the pilot after 3 months, to
ascertain if this is clinically beneficial to patients. Our primary aim is to ensure that our patients
receive the best care at the right time and this pilot will ensure that this review takes place.
2. The absence of any ongoing risk assessment documentation for patients with
mental illness within the SystemOne records at HMP Birmingham.
The Trust is restricted to what it can change on SystemOne due to it being the national
software used in prisons. We are however meeting with the software company on 27 April
2023 to discuss the concerns raised within the PFD. Any changes to be made at a national
level by SystemOne may take some time. Consequently the Trust has looked to how it will be
able introduce risk assessment documentation into the system and ensure that Trust staff
complete this in the interim.
Customer Relations │ Mon – Fri, 8am – 6pm
Website: www.bsmhft.nhs.uk
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A risk assessment has been added to the System One software that is accessible for the Trust
staff only. This will be rolled out to staff with a dissemination plan, which is attached. The plan
includes a practice alert and a Standard Operating Procedure to be sent to all clinical staff.
This has now taken place. This will set out the requirements for the risk assessments to be
completed. This will ensure that going forward all patients will receive a risk assessment when
one is necessary. The roll out of this will be complete by 20 May 2023.
I hope that we have been able to provide you with reassurance that we have taken action in
regard to the concerns that you have raised, to ensure continuous improvement in the care
we provide to our patients.
Yours sincerely,
Chief Executive
Birmingham and Solihull Mental Health NHS Foundation Trust
Ms. Emma Brown
Birmingham & Solihull Coroner’s Court
Steelhouse Lane
Birmingham
B4 6BJ
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
16 May 2023
Dear Ms Brown
Re: Regulation 28 Report to Prevent Future Deaths – Jai Singh who died on 28
January 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15
March 2023 concerning the death of Jai Singh on 28 January 2022. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Mr Singh’s family and loved ones. NHS England is keen to
assure the family and the Coroner that the concerns raised about Mr Singh’s 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 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.
NHS England is unable to comment on the matters of concern highlighted that relate
to booking of interpreters, communication, and engagement with Mr Singh’s family as
these are matters for response locally. I have considered the concern raised in your
report regarding the absence of any ongoing risk assessment documentation for
patients with mental illness, within the SystmOne records at HMP Birmingham and my
response is as follows:
Matters of Concern:
The absence of ongoing risk assessment documentation for patients with
mental illness within SystmOne records at HMP Birmingham.
At first reception into prison, a healthcare professional (or trained healthcare assistant
under the supervision of a registered nurse) carries out a health assessment of
patients.
This first night screening takes place in line with guidelines from the National Institute
for Health and Care Excellence (NICE) and all patients are asked at this assessment
if they have been convicted of murder, manslaughter, or another offence with a long
sentence. If a patient answers yes to this question, there is a specific referral made to
the Mental Health team for assessment, and this is recorded in a Health and Justice
Information System (HJIS), SystmOne template.
There is also a comprehensive section in this first night screening template relating to
mental health which asks questions around the patient’s mental health history. This
includes whether they have ever seen a healthcare professional or used a service for
a mental health problem such as psychiatry, general practice, psychology, counselling,
community mental health services, alcohol or substance misuse or learning disability.
If the patient answers yes to this question, they will be asked for further detail and a
referral made to the Mental Health team, again being recorded using the template
available on SystmOne.
There are several opportunities during the first night screening where an Assessment,
Care in Custody and Teamwork (ACCT) can be requested or opened if concerns are
identified.
Within 7-days of the first health assessment, a further second-stage health
assessment for every person in prison is conducted. Included in this is a correctional
mental health screen (CMHS), also recorded on the available SystmOne template and
based on the results of this, a further mental health assessment should either be
conducted, or a referral made for this and again recorded on SystmOne.
In terms of training in support of the use of SystmOne, North of England
Commissioning Support Unit (NECS) is the implementation and training partner for
The Phoenix Partnership (TPP) SystmOne and works across the Health and Justice
environment.
In 2020, at the refresh of the Secure Environment Assessment Toolkit (SEAT) suite of
clinical templates, each site received a group overview of how to complete the clinical
template suite. This training was delivered by a Regional Project Manager and training
expert and documentation around attendees to these sessions was maintained.
The documentation including technical guidance around the SEAT implementation,
and how to complete the templates, is stored on the NECS training platform. All
users have access to this platform, and it includes an overview to completing
national clinical templates.
There is also provision to request further one-to-one training from NECS, which can
be delivered face-to-face or via Microsoft Teams.
The fact the mental health multi-disciplinary team (MDT) does not include a
psychiatrist.
MDT members can include a variety of practitioners, specialists and care-givers from
a wide range of different services, including Psychiatrists. NHS England would not
however prescribe to have a psychiatrist included in every MDT.
The decision about who is best placed to sit in specific MDT meetings, is led by the
history and presentation of the patient, and on a case-by-case basis which is made
locally.
The absence of ongoing risk assessment documentation for patients with
mental illness within the SystmOne records at HMP Birmingham.
Risk assessments are carried out in line with relevant National Institute for Health and
Care Excellence (NICE) guidance for the mental health assessment of people in
prison. There are templates available within SystmOne for this purpose. Any concern
relating to record keeping within SystmOne, is for Birmingham and Solihull Mental
Health Foundation Trust (BSMHT) to respond to locally as a separate matter.
I do hope this reassures you that in terms of mental health assessment, information
and prompts available to staff, there are templates available on SystmOne which
provide this and are used in prison healthcare and there is training in place to support
this. If there is evidence that current information relating to the templates is lacking,
we would need to understand more about specifically what is needed, and a risk
assessment could then be deployed nationally to review and update.
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
Ms Emma Brown
HM Coroner Birmingham and Solihull
The Birmingham and Solihull Coroner’s C ourt
Steelhouse Lane
Birmingham
B4 6BJ
19th May 2023
Dear Ms Brown
Re: Regulation 28 report – Jai SINGH
Thank you for your email of 16th March 2023. I apologise for the delay in responding.
I have previously been a fulltime NHS GP, and for the last 19 years been the clinical director and
principal clinical safety officer for TPP, a company based in Leeds that supplies the SystmOne
product for use by the prison service (inter alia). The product has been in continuous usage for 24
years. There is only one version of SystmOne.
I am grateful that colleagues from NHS England were able to share
report details the way SystmOne is used in the prison service and usefully highlights the different
areas of responsibility with regard to usage of electronic medical records and training.
’ report. His
SystmOne provides our users with many tools to support patient care – the creation of data entry
templates, the development of decision support for particular circumstances, and the ability to
produce alerts, reminders and warnings as data is entered. The decision to use these, and how they
should be used is in the hands of the commissioner of the system. Professor Powis’ report details
how the system is used for mental health assessments.
I agree with your statement that systems used in mental health settings provide a rolling risk
assessment document that clinicians are required to review and update at certain points in a
patient's management. The SystmOne mental health module is used in a third of Mental Health
Trusts in England and supports this functionality. This exact functionality is not available in SystmOne
prisons (as it was not commissioned to deliver this1) but equivalent data entry and alerting can be
created (as above) using the in-built Clinical Development Kit.
1
equivalence ‘… with that available within the wider community.’
makes reference to the fact that prison healthcare is commissioned under the principle of
From a system perspective I am confident that SystmOne is working correctly and in a safe manner.
Please let me know if you have further concerns.
Yours sincerely
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