Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0499, written 5 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Dec 2023 |
|---|---|
| Reference | 2023-0499 |
| Deceased | Samuel Jones |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | State Custody related deaths |
| Organisation named | Oxleas 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.
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: 1. The Rt Hon Edward Argar MP, Minister of State for Prisons, Parole and Probation 2. 3. , Director General Chief Executive of His Majesty's Prison and Probation Service (HMPPS) , Chief Executive of NHS England 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 11th On the Samuel Lewis Jones, born on the 24th November 1998. May 2021 an investigation was commenced into the death of The investigation concluded at the end of the Inquest on the 28th November 2023. The Medical Cause of Death was: la Ligature Suspension The conclusion of the Inquest heard before a jury was a narrative conclusion that "Sam suspended himself by a ligature, there is insufficient evidence that has been presented to the jury to show that Sam had or had not intended to take his own life." 4 CIRCUMSTANCES OF THE DEATH The deceased died on the 30th April 2021 after he suspended himself by a ligature in his cell at HMP Portland, Portland, Dorset. 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 1 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. Sam's mother died by an act of self-harm on the 12th April 2014. Sam was greatly affected by his mother's death which was known by the prison and healthcare staff at HMP Portland, however the date of her death was not identified in the prison or healthcare records and was not known to those caring for Sam. Had both prison and healthcare staff been aware of the date they would have spoken to Sam around this time to provide support to him. Prisons nationally use a records system called NOMIS and healthcare providers in prisons nationally use a records system called SystmOne. There is no mechanism in NOMIS or SystmOne to highlight key or trigger dates that may have an impact upon a prisoner. Following the evidence at this Inquest, local processes have been immediately put into place at HMP Portland to ensure that prisoners will be asked about any significant or trigger dates at the initial and second healthcare screen when they arrive at the prison. This information will be recorded on SystmOne manually in the risk information box and a task will be scheduled close to the key date. Prison staff do not have access to SystmOne. This is a local process and not a national one and this issue is likely to arise at all prisons in England and Wales. There is no national guidance or policy on this and no specific question on the SystmOne records, or location in the NOMIS records, to enquire into, or highlight, significant dates for the prisoner. ii. When meeting with a prisoner, prison staff have access to the NOMIS records, however, most of the prison staff who gave evidence at the Inquest stated that they would not read the full records and just look at the last 2 or 3 contacts. Due to the current reduction in staffing levels at HMP Portland as a result of difficulties in recruitment, which is affecting staffing within prisons nationally, staff gave evidence that they do not have the time to consider the NOMIS records in full for routine checks or welfare checks under the keyworker scheme. Evidence was also given by a Supervising Officer at the prison that when ACCT reviews are conducted this could be the first time they meet the prisoner and they do not have time to go through all the records due to current staffing pressures. There is no ability to search the NOMIS records by a key word search as there is on SystmOne, so key information about a 2 prisoner may be buried within the case notes section on NOMIS which can be very lengthy. To find out this information staff would have to go through all the records which as stated above is not practically possible due to current staffing levels. As a result information can be missed. Although there is an alerts page on NOMIS this only allows certain standard entries and there is no free text box to allow bespoke entry of information. This results in key information about a prisoner being overlooked. Some witnesses gave evidence that they were not aware of Sam's history contained in the NOMIS records and had they been, they would have acted differently. There is a new version of NOMIS which although being used in the Prison Service at the moment, is still under development which could address these issues. iii . In prison, prisoners are prescribed medication to take either under supervision or in their own possession. This means that a prisoner can self-medicate their cell. Prescriptions of in medications can be given to cover a supply for up to 28 days. Prior to a determination as to whether it would be safe for a their possession, a risk prisoner assessment is undertaken both around the type of medication and the prisoner's individual risks. to have medication in Sam was prescribed and was permitted to take this in 26th possession for a period of 7 days. He last collected this on January 2021, over 3 months before his death. Following his death, he was found to have in his blood and was found in his cell. It may have been that he was illicitly obtaining , however it may also be that he had left over medication from that he had been prescribed previously. When a prisoner stops taking medication, healthcare teams have little option other than asking if a person has any leftover medication and are dependent on the prisoner handing any excess medication back. Healthcare teams do not have the power to search a cell although can pass information on to the prison staff if they have any concerns regarding the stockpiling or access to medication in the cell. There is a local operating policy in place within the healthcare department at HMP Portland to cover medication. Following the evidence heard during the Inquest, this has already been amended to ensure steps are taken to try to ensure that a prisoner does not have any medication in their cell which they should not have. There is, however, no national guidance to assist both healthcare and Prison Service staff deal with this issue and it is for individual orisons to set up their own orocesses. 3 2. I have concerns with regard to the following: i. ii. iii. iv. The lack of flagging of, and access to, key dates which may have an impact on prisoners' safety. The lack of national Prison Service or NHS guidance on how to manage key dates where risks to the safety of the prisoner may be increased, such as a bereavement or traumatic incident or any other key dates. The accessibility of information recorded on NOMIS and the potential to miss key information which could impact on risk assessments. lack of national guidance around The the operation of in possession medication in prisons either by HMPPS or NHS England to ensure prisoners do not stockpile or retain medication when they have stopped using it. 6 ACTION SHOULD BE TAKEN 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 January 2024. 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) Sam's family (2) The Ministry of Justice/HMP Portland (3) Practice Plus Group (4) Oxleas NHS Foundation Trust (5) Change Grow Live I am also under a duty to send the Chief Coroner a copy of your response. I have also forwarded the report to the following who may find the report of interest: , Director General of the Department of Health and Social Care 4 , Chief Executive Officer, Public Health England 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 S ign~ 5th December 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.
Director General of 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 3 April 2023 Dear Ms Griffin Thank you for your Regulation 28 report of 5 December 2023, addressed to the Minister of State for Prisons, Parole and Probation, the Director General Chief Executive of HM Prison and Probation Service, 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 Jones’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. You have raised four matters of concern, regarding: the recording and use of information about significant dates for individuals that may impact on their safety; the management of individuals during such periods; accessibility of information on the National Offender Management Information System (NOMIS); and the lack of guidance about the issue of stockpiling in- possession medication. I understand that NHS England will be providing a separate response on the matters that are of relevance to their work. Turning first to your concerns about key dates, as you know, NOMIS allows information to be shared throughout the system both within an establishment and nationally. We recognise that NOMIS, is no longer fit for purpose, and are currently developing a new case management system, Digital Prison Services (DPS). Whilst neither NOMIS nor DPS is currently able to record key dates, this is something that we will revisit as we continue to develop DPS. Our main focus for now, is to build the core functionality that is needed in DPS in order to enable us to cease the use of NOMIS. Our guidance on understanding risk and sharing information explains that significant dates for individuals, such as anniversaries, can be periods of increased risk and emphasises the A2 importance of recording information about such dates. We know that many prisons maintain local databases for this purpose. The importance of awareness that key dates may be triggers will also be made clear in the new Safety Policy Framework that we will shortly be issuing, which will be supported with guidance for staff about how to provide suitable, co-ordinated care during such trigger periods. In the meantime, we will issue a Senior Leaders Bulletin on the importance of recognising key dates and encouraging the use of local databases. With regard to your third concern I have acknowledged above that NOMIS is not fit for purpose and explained that we are working on the development of DPS as a replacement. NOMIS does, however, provide the capacity for staff to search notes in various ways, including by type, subtype and date. The ability to search for key words is currently under consideration in the development of DPS, and we anticipate that this function will be available by 2025. With regard to your final concern, decisions about which medication can be issued to be held in possession by prisoners are primarily a matter for healthcare providers, but prison staff have a role to play, and this is an area in which collaborative working and appropriate information sharing are crucial. There are a number of prison policies that cover the stockpiling of medication, or its retention after an individual has ceased a course of treatment. Depending on the circumstances, healthcare staff may consider further treatment or intervention or it could constitute possession of an unauthorised item, which would be an offence against prison discipline as set out in the Adjudications Policy Framework. In these circumstances prison staff are permitted to remove medication as an unauthorised item in accordance with the Searching Policy Framework, and the Prisoners’ Property Policy Framework has recently been amended to require the removal of medication during cell clearances. As always, we remain committed to prisoner safety as our key priority. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address them. Yours sincerely, Director General of Operations A3
OFFICIAL Rt Hon Edward Argar MP Minister of State for Justice Rachael Clare Griffin Senior Coroner for the Area of Dorset HM Coroner’s Office Town Hall Bournemouth BH1 6DY Dear Coroner, 3 April 2024 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – SAMUEL JONES Thank you for your Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Samuel Jones, who died on 30 April 2021 at HMP Portland. I have read your report with care as a death in custody is a tragic event for families and friends, as well as other prisoners and staff, and learning lessons to improve the safety of those in prison custody is essential. I understand that you will share this letter with Mr Jones’ family and I would like to offer them my sincere condolences for their loss. The concerns you have raised within your report are operational issues and it is therefore appropriate for , DG Operations, HM Prison and Probation Service (HMPPS), to respond to them. I have seen the response from by HMPPS to address your concerns. and I endorse the content of it, which sets out the action being taken RT HON EDWARD ARGAR MP T +4420 3334 3555 F +44870 761 7753 E https://contact-moj.service.justice.gov.uk/ www.gov.uk/moj 102 Petty France London SW1H 9AJ A1
Ms Rachael Clare Griffin HM Senior Coroner Coroner’s Office for the County of Dorset Town Hall Bournemouth BH2 6DY National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 26 January 2024 Dear Ms Griffin, Re: Regulation 28 Report to Prevent Future Deaths – Samuel Lewis Jones who died on 30 April 2021. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 05 December 2023 concerning the death of Samuel Lewis Jones on 30 April 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Samuel’s family and loved ones. NHS England is keen to assure the family, and the coroner, that the concerns raised about Samuel’s care have been listened to and reflected upon. I respond to each of the matters of concern raised in your Report below. 1. The lack of flagging of, and access to, key dates which may have an impact on prisoners’ safety. Ownership of the Health and Justice Information Service (HJIS) lies with NHS England, which commissions the NHS North of England Commissioning Support Unit (NECS) to manage a programme of upgrades to the system. NECS explains that there are two options available for flagging key dates on HJIS, which include a patient status marker or alert (PSA). This would appear on the patient home screen and use a report, set up to support the alert, to send a task to a specific user on a specified date. This would be a ‘batch’ run and would continue until the patient’s discharge or, manual removal of the PSA. NECS also confirms that most system administrators and regional performance leads know how to set up PSAs and batch reports, and training and guidance relating to this is distributed. The second option is a scheduled task, which can be sent to a specific user or group, on a specified date. This method of flagging a key date is simpler to set up but requires a manual reset annually. 1 Recommendations | Physical health of people in prison | Guidance | NICE A4 2. The lack of national Prison Service or NHS guidance on how to manage key dates where risks to the safety of the prisoner may be increased. Such as bereavement or traumatic incident, or any other key dates. 3. The accessibility of key information recorded on NOMIS and the potential to miss key information which could impact on risk assessments. , Director General for His Majesty’s Prison and It is my understanding that Probation Service (HMPPS) is intending to write to you directly in response to the matters highlighted in concerns two and three. I note you reference in the report that in response to the learning from this incident, a local process has been put in place by HMP Portland to ‘ensure prisoners will be asked about any significant or trigger dates at the initial and second healthcare screen when they arrive at prison’. As you have identified this as good practice, NHS England will contact HMP Portland to obtain more information, and share this learning and subsequent action with regional health and justice commissioners, requesting they bring this to the attention of their own healthcare providers. 4. The lack of national guidance around the operation of in possession medication in prisons either by HMPPS or NHS England to ensure prisoners do not stockpile or retain medication when they have stopped using it. The National Institute for Health and Care Excellence (NICE) guideline NG57 (1) published in November 2016, provides guidance for managing medicines, including those held in-possession. This guidance references review and repeat of a person’s risk assessment for in-possession medication in certain circumstances. An example of this is where security concerns are raised which may include hoarding or stockpiling or, where prescription requesting or medicines information held by the healthcare team, suggests non-adherence to treatment. As for people in the community, patients in prison are advised to return any unused medicines for disposal. This approach is underpinned by NICE guidance CG76 on medicines adherence published in January 2009 which can be found here and national professional standards the Royal Pharmaceutical Society in 2017, available here. for secure environments published by Had any concerns been raised that Samuel may have been hoarding or stockpiling his medication (Sertraline), responsibility for a cell search lies with HMPPS. NHS England contacted HMPPS to discuss this matter of concern and it has been confirmed this will be addressed in the direct response from the HMPPS Director General. I would also like to provide assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures key learning and insights around events are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. A5 Thank you for bringing these important issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, Medical Director for Professional Leadership and Clinical Effectiveness NHS England A6
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