Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0066, written 5 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Feb 2024 |
|---|---|
| Reference | 2024-0066 |
| Deceased | Abdullah Popalzai |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | State Custody related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Coroner ME Hassell HM Senior Coroner Inner North London REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Abdullah Popalzai died 29 November 2019 THIS REPORT IS BEING SENT TO: 1. , Chief Executive Officer, NHS England, PO Box 16738, Redditch, B97 9PT 1 CORONER I am Sarah Bourke, HM Assistant Coroner for the coroner area of Inner North London. 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 4 December 2019, I commenced an investigation into the death of Abdullah Popalzai (20 years). The investigation concluded at the end of the inquest on 29 November 2023. The conclusion of the inquest was that the medical cause of death was 1a Suspension. A conclusion of suicide with an additional narrative was returned by the jury. The Jury found “Mr Popalzai died in his cell in the inpatient wing at HMP Pentonville on 29 November 2019. He was suspended from a ligature ” The accompanying narrative read as follows: present and secured with security screws, Mr Popalzai would not have been able to attach the ligature to this point. . If the cover had been properly An ACCT was not opened for Mr Popalzai. If an ACCT had been opened, staff on the healthcare wing would have had greater visibility of the self-harm risk to Mr Popalzai identified by the psychiatrist at court. Mr Popalzai was recommended to be admitted to a hospital facility. If a suitable bed and transport had been available earlier, Mr Popalzai could have received urgent medical treatment for his acute psychosis as advised by multiple medical practitioners. It is likely that Mr Popalzai became aware during the night of 28 November 2019 of his impending transfer on 29 November 2019. Mr Popalzai had stated on multiple occasions that he would hang or kill himself if he were to be transferred to a hospital. 4 CIRCUMSTANCES OF THE DEATH Mr Popalzai was a remand prisoner at HMP Pentonville. A Mental Health Act assessment carried out at the Magistrates Court on 24 September 2019 decided that he should be detained under Section 2 of the Mental Health Act. However, as there were no hospital beds available at the time that Mr Popalzai’s case was heard, he was remanded in custody to HMP Pentonville. Mr Popalzai was transferred to the inpatient wing at HMP Pentonville on 29 September 2019. There were significant barriers to communicating with Mr Popalzai as he spoke predominantly in Pashto. Throughout his time in the inpatient unit, Mr Popalzai was acutely psychotic. He was aggressive and most interactions with psychiatrists, healthcare staff and prison officers took place through the cell door. Mr Popalzai consistently refused to take any medication as he did not accept that he was mentally ill. Mr Popalzai stated on several occasions that he would hang himself if transferred to a psychiatric hospital. On 9 October 2019, Mr Popalzai was assessed by a psychiatrist who found that he was psychotic and needed to be transferred to hospital for treatment under section 48 Mental Health Act 1983. The Crystal Ward, which is the psychiatric intensive care unit at the Newham Centre for Mental Health, was identified as the appropriate unit. A second assessment was carried out by a psychiatrist from the Crystal Ward on 18 October. The 2nd psychiatrist agreed that Mr Popalzai should be detained on the Crystal Ward for assessment and treatment under section 48 Mental Health Act on 24 October 2019. However, there were no beds available on Crystal Ward at that time. On 21 November 2019, the Crystal Ward advised that a bed would become available the following week. A warrant authorising transfer was issued by the Ministry of Justice and arrangements were made for Mr Popalzai to be transferred to the Crystal Ward on the afternoon of 29 November 2019. At around 12.30 pm on 29 November 2019, Mr Popalzai was found hanging in his cell. Attempts were made to resuscitate Mr Popalzai but his death was confirmed by paramedics at the scene. The psychiatric evidence was consistent that: 1) the only effective treatment for Mr Popalzai’s psychosis was anti- psychotic medication; 2) anti-psychotic medication could not be given to him against his wishes in a prison setting. As a result, he needed to be transferred to an appropriate psychiatric unit. 3) Mr Popalzai’s mental health deteriorated in the time that he was waiting for a psychiatric bed to become available. I also heard evidence that a significant number of prisoners from HMP Pentonville were transferred to psychiatric units under the Mental Health Act each year. I was told that the experience of psychiatrists at the prison was that the target time of 14 days from 1st assessment to transfer set out in the statutory guidance was seldom met. I was also told that significant delays in beds becoming available were extremely common and delays of up to 6 months were not unheard of. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – 1) Prisoners who are acutely psychotic and refusing treatment that requires transfer to hospital under the Mental Health Act are being left untreated and at risk of further deterioration due to a shortage of suitable psychiatric hospital bed spaces becoming available in a timely way. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 April 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: • Ministry of Justice • Practice Plus Group (Previously Care UK) • Barnet, Enfield and Haringey NHS Foundation Trust • East London NHS Foundation Trust • The Prison and Probation Ombudsman I have also sent it to the North East London NHS Foundation Trust who may find it useful or of interest. 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 SARAH BOURKE HM Assistant Coroner 5 February 2024
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.
Sarah Bourke
St Pancras Coroner’s Court
Camley Street
London
N1C 4P
020 7974 4545
Dear Coroner
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
28 March 2024
Re: Regulation 28 Report to Prevent Future Deaths – Abdullah Popalzai who
died on 29 November 2019.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated
5 February 2024 concerning the death of Abdullah Popalzai on 29th November 2019.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Abdullah’s family and loved ones. NHS England
is keen to assure the family, and the coroner, that the concerns raised about Abdullah’s
care have been listened to and reflected upon.
Your Report raised the concern that prisoners who are acutely psychotic and refusing
treatment that requires transfer to hospital under the Mental Health Act, are being left
untreated and at risk of further deterioration due to a shortage of suitable psychiatric
hospital bed spaces becoming available in a timely way.
I note from your Report there were two incidents which included:
a) assessment for a bed whilst in court, a bed couldn’t be found in time and Mr
Popalzai was therefore remanded in custody; and
b) access to a hospital bed following being assessed on 09 October 2019 and 18
October 2019 as suitable for admission under the Mental Health Act.
NHS England is committed to ensuring access to timely, responsive, and least
restrictive mental health care and is already working to address issues in this area by
focusing on increasing access to hospital beds pre-sentence, rather than prison being
used as a place of safety.
Access to mental health beds for people in custody should be considered as part of
wider plans for how systems meet the mental health needs of the population. The
number of mental health beds required to support a local population is dependent on
both local mental health need, and the effectiveness of the whole local mental health
system in providing timely access to care, and supporting people to stay well in the
community, therefore reducing the likelihood of an admission being necessary.
In some local areas there is a need for more beds, which is being addressed in part
through investment in new units. This should be considered as part of a whole system
transformation approach.
This is supported by the NHS Long Term Plan (LTP), which is seeing an additional
£2.3bn funding invested in mental health services from 2019/20 – 2023/24, around
£1.3bn of which is for adult community, crisis, and acute mental health services to help
people get quicker access to the care they need and prevent avoidable deterioration
and hospital admission.
To improve access to local beds and flow through acute pathways, an additional
£700m was made available during the winter period in 2022/23 and a further £1.6bn
via the ‘better care’ fund from 2023-25. This funding can be used to support mental
health inpatient services as well as the wider system, which should help to reduce
pressures on local inpatient services so those who need to access beds can do so
quickly and locally.
I would like to assure you that following the sad death of Mr Popalzai, lessons have,
and will continue to be learnt. NHS England’s Health and Justice team is undertaking
significant work around early identification, treatment and support of people who
require mental health support, along with increasing access to hospital beds whilst
people are held on remand and focusing on speeding up access to a bed for those
held in custody.
His Majesty’s Inspectorate of Prisons (HMIP) recently published the report The long
wait: A thematic review of delays in the transfer of mentally unwell prisoners which
outlines similar issues. NHS England is also addressing the areas of concern and
lessons learnt within this report.
This ongoing work will ensure people have access to the right care and treatment,
including access to the right hospital bed for people within the Criminal Justice System
(CJS).
I would also like to provide further assurances on 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 that key
learnings and insights around preventable deaths are shared across the NHS at both
a national and regional level and helps us pay close attention to any emerging trends
that may require further review and action.
Thank you for bringing these important patient safety issues 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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