Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2024-0126, written 16 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Nov 2023 |
|---|---|
| Reference | 2024-0126 |
| Deceased | John Singleton |
| Coroner | Kate Ainge |
| Coroner area | Cheshire |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 NHS England 1 CORONER I am Kate AINGE, Assistant Coroner for the coroner area of Cheshire 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 16 September 2019 I commenced an investigation into the death of John Joseph SINGLETON aged 42. The investigation concluded at the end of the inquest on 16 November 2023. The conclusion of the inquest was that: Suicide 4 CIRCUMSTANCES OF THE DEATH with a history of depression following John Joseph Singleton significant family bereavements and epilepsy secondary to a head injury. Compliance with medications for these conditions had previously been sporadic. John had a history of previous incarcerations when he arrived at HMP Risley in May 2019 to serve a 10 month sentence for attempted burglary. In August 2019 John began acting bizarrely, had fixed thoughts of persecution and paranoia but did not disclose any thought of self-harm or suicide ideation. Periods of intermittent self-isolation followed these paranoid thoughts. An Assessment, Care in Custody and Teamwork document was initiated on Saturday 31st August 2019 to identify the issues, offer support and put monitoring in place, but John's mental health continued to deteriorate. On 1st September 2019 during the prison transition period from night to day state, John was on his own in his locked cell with the intention of ending his life. At 7:56am access to the cell was gained and John was found hanging The ligature was cut to release John and appropriate emergency response made. Upon arrival paramedics took over emergency care, obtained a cardiac output and transferred John to Warrington Hospital where he later died on the 10th September 2019 at 17:25. Aspects of the systems relating to medicines non-compliance and mental health referrals at HMP Risley were lacking but did not cause or contribute to John's death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the Regulation 28 – After Inquest Document Template Updated 30/07/2021 circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) During the inquest it came to light that John was prescribed medications for depression and epilepsy whilst incarcerated. His compliance with medications was found to be sporadic and as a result he failed to collect a number of prescriptions to enable continuity of his medication. Some of the reasons around this were anxiety in attending to collect his medications and also periods of self-isolation. Whilst Healthcare at the prison were aware of some of the periods of non-compliance and in fact a GP referral and action was taken to enable John to have weekly in-possession medication to support his compliance, other periods were not flagged or identified and it became clear that monitoring those prisoners who are not medication compliant, particularly if receiving weekly or monthly medication was challenging due to the SystmOne electronic patient system not being able to flag a warning for non-compliant prisoners for early identification and referral. John subsequently suffered a decline in his mental health and whilst the lack of medication compliance was not deemed to cause or contribute to his death, the importance of consistent medication for medical conditions and early identification of prisoners who do not comply was an issue which was raised and explored within the inquest. The action taken by the prison after John's suicide was to put a cross check system in place by which pharmacy technicians cross reference the medication by way of a weekly stock check to identify the prisoners who have not collected medications or had the same dispensed, so that referrals can be made to the Healthcare team and or GP to task. Such a system is less than ideal as it is both resource heavy, carries real risks of not being accurate and in the Coroners view, for prisoners in possession of medication, there is likely to be a much longer period before non-compliance is identified which carries real risks of fatalities. The inquest touched upon the SystmOne electronic record used across the Prison estates by Healthcare. From the evidence it appears that the system has a facility to flag concerns and tasks to action and in fact, certain flags are generated automatically to alert healthcare staff to live issues around a prisoner, however, something as simple and the system generating a warning flag to identify when medication is not dispensed or collected was neither possible nor available on the current operating system. An automated flag alert via the system upon the failure to dispense or collect medication by a prisoner would be a far more efficient and effective way in which prisoners failing to comply with medications could be identified and actioned quickly and in which future deaths could be prevented. 6 ACTION SHOULD BE TAKEN In my opinion 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, namely by January 11, 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 Bridgewater Community Healthcare Greater Manchester Mental Health Trust HMP Risley Regulation 28 – After Inquest Document Template Updated 30/07/2021 I have also sent it to who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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: 16/11/2023 Kate AINGE Assistant Coroner for Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Ms. Kate Ainge
The West Annexe
Town Hall
Sankey Street
Warrington
Cheshire
WA1 1UH
Dear Ms Ainge,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
3rd May 2024
Re: Regulation 28 Report to Prevent Future Deaths – Mr John Joseph Singleton
who died on 10 September 2019 whilst in the custody of HMP Risley.
Thank you for your Report to Prevent Future Deaths (hereafter ‘Report’) dated 16
November 2023 concerning the death of John Joseph Singleton on 10 September
2019.
In advance of responding to the specific concerns raised in your report, I would like to
express my deep condolences to Mr Singleton’s family and loved ones. NHS England
is keen to assure the family, and the coroner, that concerns raised about Mr
Singleton’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused to John’s family or friends. I realise that
responses to Coroner Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones and appreciate
this will have been an incredibly difficult time for them.
Your Report raised the concern that there is a lack of functionality on the Health and
Justice Information Service (HJIS) known as SystmOne, to be able to flag a medication
non-compliance warning for early identification and referral and that an automated flag
alert via the system would be a more efficient and effective way to monitor non-
compliance.
In prisons people are risk assessed to determine if they can have their medicines in
their possession (for self-administration) or are supplied each dose of some or all of
their medicines under direct supervision by a healthcare professional (not in
possession).
HJIS is not able to report on omitted doses at a national level however, local reports
can be produced that show failed collections for a specific date, which can inform
follow up. National standards published by the Royal Pharmaceutical Society expect
provider services to have mechanisms in place to identify and follow up if 3
consecutive doses, or to follow up if supplies are not collected. It is worth noting that:
• as in the community, once a person has their medicines in their possession,
compliance is not checked by the healthcare team routinely. Checks are made
as part of a medicines or clinical review by the GP.
• A person can collect in-possession medicine any time between when it’s ready
to collect and when they need to take the first dose from the supply. This means
the date for collection shown in HJIS may not be the date the supply needs to
be used.
In prisons this means that the HJIS reports are used to check and follow up missed
collections for not in-possession medicines as these represent missed doses. For in-
possession medicines, routine weekly or monthly checks of the medicines supply
rooms for any uncollected medicines would trigger a follow up where there is a clinical
concern such as mental health or epilepsy medicines.
It is our view that a flag in a record is not a solution that would improve safety, as the
flag would not be seen until a clinician opens
that patient record, whereas
a HJIS generated report will detail every individual who missed doses, or supplies, in
the timeframe reported on.
I can advise that work is underway now to investigate the reporting functions in HJIS
to establish whether there is a suitable mechanism that can be used by provider
services, to identify non-collections of in-possession medication. This would be used
to prioritise medicines supply room checks and follow up. Once an effective way
forward is identified and agreed, the national NHS England Health and Justice team
will work to facilitate roll out across the estate.
In the interim, in response to the concerns noted, NHS England's National Director of
Health & Justice, Armed Forces and Sexual Assault Services Commissioning, will
write to Health and Justice regional teams sharing these concerns, and asking
commissioners to work with prison healthcare provider organisations, to remind all
staff of the requirement to monitor uncollected in-possession medicines and the
current options available within HJIS and in local processes to support this.
The findings and information will also be taken to a future NHS England Health and
Justice Delivery Oversight Group (HJDOG). The HJDOG is the senior leadership
forum, which holds responsibility for the oversight of delivery and continuous
improvement in Health and Justice commissioned services, through both the national
and regional teams, with a focus on improving health outcomes and reducing
variation across England. These matters will be discussed, and regional
commissioners will be asked to give assurance at a subsequent HJDOG meeting
that the proposed action has been taken.
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, such as the sad death of Mr Jones, 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.
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
National Medical Director
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