Jacob Billington

Louise Hunt 
Senior Coroner for Birmingham and Solihull 
The Birmingham and Solihull Coroner’s Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

Legal Department 
B1 – Unit 1 
50 Summer Hill Road 
Birmingham 
B1 3RB 

Tel:  

BY EMAIL ONLY 

Our Ref:    

Your Ref:  

Date: 7 May 2024

Dear Mrs Hunt, 

Re: Prevention of Future Deaths Jacob Billington 

Thank  you  for  your  Prevention  of  Future  Death  (PFD)  report,  which  I  understand  has  also 
been issued against the other Interested Parties within Mr Billington’s inquest. I would like to 
take this opportunity to offer my sincere condolences to Jacob’s family at this time and offer 
my assurances that as a trust we have carefully considered the issues that arose during the 
inquest and will use this time to ensure that lessons are learned for patients and the public in 
the future.  

In response to the following points: 
Management of release and lack of interagency working.  
Cross  agency  guidance  regarding  release  of  high-risk  prisoners  with  mental  health 
difficulties at their sentence end date.  
West Midlands MAPPA  

The Deputy Medical Director chaired an initial scoping meeting in response to these issues 
identified by the PFD on 10th April 2024, culminating in agreement on 3 primary areas of focus 
:  

1.

2.

BSMHFT involvement in MAPPA. We acknowledge the need for a sustainable
engagement  strategy  with  the  Multi-Agency  Public  Protection  Arrangements
(MAPPA). Currently the Prison Discharge Coordinator acts as the main link with
the  MAPPA  process.  There  is  a  need  to  understand  if  this  is  sustainable  and
suitable. There is a plan to include the BSMHFT MAPPA Clinical Lead to support
in outlining this and identifying any gaps to be alternatively planned for.

Role of the Prison Discharge Coordinator. The Standard Operating Procedure
has  been  revised.  In  addition  to  this  there  is  an  intention  to  review  the  Job
Description of this role and understand in more depth the scope of what this role
can achieve currently or will need to achieve in the future including any potential
additional  resource  requirements.  This  review  is  aimed  at  aligning  the  role's

 Chair: 

  │  Chief Executive: 

  │  Website: www.bsmhft.nhs.uk 

Customer Relations: Mon–Fri, 8am–6pm  │  Tel: 0800 953 0045  │  Email: bsmhft.customerrelations@nhs.net 

 
 
 3. 

capabilities  with  the  evolving  requirements  of  our  service  and  ensuring  it  can 
effectively contribute to safer community reintegration 
Interface between Prison In-reach and the CMHT- A comprehensive review of 
the current interaction process between the Prison In-reach team and the CMHT 
is  planned.  This  will  involve a detailed  gap  analysis  to  determine  areas needing 
strengthening. We aim to develop a clear plan to enhance this interface, thereby 
improving  continuity  of  care  and ensuring that  individuals  receive the  necessary 
support as they transition from prison to community-based services. 

These workstreams are part of our ongoing commitment to make substantive, lasting changes 
that address the concerns raised. We understand the importance of ensuring these changes 
are not only implemented but are sustainable and lead to significant improvements in patient 
care and safety. We will continue to monitor the effectiveness of these changes closely and 
adjust our strategies as necessary to meet this commitment. 

To  ensure  effective  progress  in  addressing  these  areas,  we  will  establish  dedicated 
workstreams that will operate as part of a Task and Finish group.  The stakeholders for each 
workstream  will  be  responsible  for  reviewing  existing  processes  and  relevant  policies  to 
determine  if  further  action  is  required.  The  initially  identified  stakeholders  have  been  both 
cross-organisational  and  multi-professional  including  Secure  Care  Services,  the  In  Reach 
Team, Community Mental Health Services (BSMHFT and FTB) and HMP Birmingham. As this 
work progresses, if additional key stakeholders are identified, they will be included. 

Each workstream will formulate a plan, outlining specific outputs and associated timeframes.  
These plans will be overseen by the Deputy Medical Director for Quality and Safety and our 
Clinical Governance Committee. 

Through this structured approach, we aim to thoroughly analyse, carefully plan and implement 
improvements  where  needed.  Whilst  we  cannot  give  you  an  immediate  outcome  on  these 
points, we will write formally and update you in 3 months on our progress. 

In  the  meantime  we  can  offer  you  assurances  that  since  the  events  that  culminated  in  Mr 
Billington’s death the Trust has improved the structure and supervision surrounding the prison 
discharge  coordinator  roles,  such  that  the  practitioners  have  weekly  supervision  with 
opportunity to escalate cases of concern, and an improved system of referrals and discharge 
procedures, reflected in the updated standard operating protocol.  This means that in the event 
of a similar situation occurring again, there would be sufficient structure to ensure and support 
the flexibility in service provision to prevent such an individual falling between services, even 
where they had been discharged from active multiagency management by MAPPA.   

In addition to our Prison Discharge Co-ordinator we also have our RECONNECT service in 
place  which  was  not  available  previously.  Whilst  it  is  important  to  note  our  RECONNECT 
service  is  not  a  statutory  service  and  engagement  from  service  users  is  voluntary,  their 
inclusion criteria is for prison leavers with low/medium risk profiles. They offer in reach support 
12  weeks  pre-release  and  then  up  to  6  months  support  post  release  in  the  community. 
RECONNECT  is  a  vulnerability  service  supporting  multiple  service  user  needs  including 
accessing mental health support. 

They are based within HMP Birmingham however are a national service and accept referrals 
from Out of Area prisons for prison leavers relocating to Birmingham and Solihull. Additionally, 
prison leavers can be referred up to 28 days post release by probation offender managers, 
other professionals, family/friends or self-referrals. 

In addition HMP Birmingham has an in-reach mental health team. If a prisoner is released who 
is  on  the  mental  health  caseload,  the  team  would  refer  into  the  local  CMHT  if  not  already 

 
 
 
 
 
 
 
 
 known to them. If they are already known to a community CMHT we would inform them of the 
release date and they would also be invited to any Care Programme Approach. If they are 
known  to  the  Assertive  Outreach  Team  or  homeless  team  the  team  would  also  take  this 
approach. If a prisoner is receiving a service from mental health in HMP Birmingham and is 
transferred to another jail the in-reach would inform the receiving jail and hand over any clinical 
information  that  is  required.  The  in-reach  team  can  also  refer  to  RECONNECT  service  for 
prisoners who needs support in the community with mental health.  

Systemone  
Whilst this point is an issue which will need to be addressed at a more national level by other 
Interested  Parties,  the  Trust  has  also  looked  at  its  own  Systemone  interface  in  HMP 
Birmingham to see if this can be amended locally.  

We  are  satisfied  that  GP  details  are  readily  recordable  and  accessible  within  the  system.  
There is not currently a specific field for recording information by the community mental health 
team for those prisoners under the care of secondary mental health services.  This is mitigated 
because NHS staff within the prison have access to the mental health records for people from 
Birmingham and Solihull however for prisoners from outside of the Birmingham area, the Trust 
may not have this access. Therefore an approach has been made to Systemone to discuss 
the feasibility of adding this to the system locally. We anticipate we will have a decision around 
this within the next month. 

I fully appreciate your request for a detailed account of the changes we are implementing 
following the Prevention of Future Deaths report. I must emphasise that the nature of these 
changes is complex and inherently requires a strategic, phased approach to ensure they are 
sustainable and effectively address the issues identified. Significant improvements to 
practices and systems are not instantaneous but are developed over a considered period to 
ensure they are thoroughly embedded and genuinely effective. We are committed to making 
these improvements with the utmost diligence and oversight to prevent any future incidents 
and will keep all stakeholders updated as we progress. 

If we can be of any further assistance at this time, please do contact us.  

Yours  sincerely, 

Medical Director

Clyde & Co LLP, 2 New Bailey Square, Stanley Street, Salford, M3 5GS 
T +44 (0)161 236 2002  F +44 (0)161 832 7956  DX 14302 MANCHESTER 1  clydeco.com 

HM Senior Coroner, Mrs Louise Hunt 
Birmingham & Solihull Coroner’s Court 
50 Newton Street 
Birmingham 
B4 6NE 

Dear Madam 

Jacob Michael Nicholas Billington 

Direct Line: 

Email:

Our Ref: 

Your Ref: 

Client Confidential

8 May 2024

We write in response to your Regulation 28 report to prevent future deaths dated 13 March 2024 addressed to 
G4S,  Birmingham  &  Solihull  NHS  Foundation  Trust,  His  Majesty’s  Prisons  &  Probation  Service  (HMPPS),  the 
Chief Constable of West Midlands Police and Swansea Bay University Health Board. 

Ongoing Concerns Identified 

1.  The  management  of  release  and  lack  of  interagency  working.  The  management  of  the 
perpetrator’s release was not coordinated and there was inadequate communication between relevant 
agencies.    In  effect,  agencies  worked  in  silos.    Critical  information  is  not  being  shared  and  agencies 
work in different IT systems meaning there is no one place where information is collated and hence a 
comprehensive account of matters known to each agency is not easily available to those professionals 
who may need to know a high-risk prisoner’s whereabouts on release.  This concern was reinforced by 
evidence  heard  during  the  inquest  that  changes  made  since  Jacob’s  death  did  not  include 
resettlement  information being given to  Mental  Health In Reach teams in the prison.  The failure to 
share information leads to  a concern of future deaths as high risk  seriously unwell prisoners may be 
released  without  key  agencies  knowing  where  they  are  meaning  they  are  not  traced  and  treated 
assertively in the community. 

2.  SystmOne.  Details of the perpetrator’s GP and local CMHT were not recorded in an easily accessible 
format.  The format in which key information is recorded has now been amended at HMP Swansea to 
ensure  the  prisoner’s  GP  details  and  their  CMHT’s  details  (if  a  person  is  an  existing  patent  under  a 
CMHT)  are  highlighted  on  a  front  screen  page.    I  was  informed  that  this  change  in  information 
management and presentation within SystmOne is unique to HMP Swansea and is not the practice in 
other prisons.  I am concerned that there remains a risk that staff treating patients in prison may not 
have easy access to (and so overlook) this key information. 

3.  Cross agency guidance regarding release of high-risk prisoners with mental health difficulties at 
their sentence end date.   There are no provisions available nor any cross agency guidance in place 
for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release 
planning and maximum support in the community. 

Clyde & Co LLP is a limited liability partnership registered in England and Wales under number OC326539 and is authorised and regulated by the Solicitors Regulation Authority under number 
460690.  A list of members is available for inspection at its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR.  Clyde & Co LLP uses the word "partner" to refer to a 
member of the LLP, or an employee or consultant with equivalent standing and qualifications. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4.  West Midlands MAPPA has a prison discharge coordinator role.  It was clear from the evidence at the 
inquest that this role was not fully understood by other agencies and what information needed to be 
shared was not clear.  The new policy drafted by BSMHT remained confused as to which cases were to 
fall within the responsibility of the prison discharge coordinator role.  There remains a risk of further 
deaths as the role is not properly understood and information sharing is not effective. 

Response 

G4S  confines  its  response  to  the  first  concern  identified  relating  to  the  management  of  release  from  prison 
and interagency working.   

G4S has no power to take action regarding concerns 2, 3 and 4, and, therefore, is not in a position to assist 
HM Senior Coroner with regard to these concerns. Other interested persons to whom the Regulation 28 report 
has been addressed are better able to consider the concerns raised, take action and/or explain why no action 
is proposed. 

In  addition,  G4S  has  no  power  to  influence  the  management  of  release  of  prisoners  from,  and/or  to  ensure 
interagency working at, private prisons operated by other providers or HMPPS operated prisons. 

Offender  management  in  all  prisons  across  England  and  Wales,  including  all  privately  operated  prisons,  is 
delivered  pursuant  to  a  HMPPS  prescribed  delivery  model.    Prisoners  are  case  managed  through  their 
custodial  sentence  by  a  prison  based  Offender  Management  Unit  (OMU)  pursuant  to  the  national  Offender 
Management in Custody (OMiC) model, which provides a framework to coordinate and set out the sequence 
for  a  prisoner’s  journey  through  custody  to  post-release.    This  model  applies  to  all  prisons  in  England  and 
Wales. 

Qualified  probation  officers  and  senior  probation  officers  employed  by  the  Probation  Service/HMPPS  are 
based  at  HMP  &  YOI  Parc.    All  high-risk  prisoners  are  managed  by  qualified  Probation  Service  offender 
managers working at the prison. 

HMPPS has responsibility for provision and operation of resettlement services.  Such resettlement services at 
HMP  &  YOI  Parc  are  commissioned  by  HMPPS  from  external  providers  who  are  based  within  the  prison  to 
facilitate  resettlement  services  for  prisoners  approaching  release  from  custody.  G4S  is  not  party  to  the 
procurement  or  placement  of  resettlement  services  within  HMP  &  YOI  Parc  or  the  direct  delivery  of  these 
services.    G4S’  focus  is  on  ensuring  alignment  and  integration  with  third  party  service  providers  to  ensure 
effective interagency working. 

Resettlement  services  have  responsibility  for  providing  resettlement  support  to  prisoners,  including 
coordinating referrals and signposting to services such as housing and DWP benefits. 

Responsibility for  case  management of any prisoner  under the OMiC model passes to the Probation Service 
Community Offender Manager when a prisoner reaches a point which is eight and a half months prior to their 
release date.  This includes responsibility for managing the prisoner’s release and coordinating liaison between 
relevant  agencies  involved  and  includes  the  sharing  of  information  with  all  other  relevant  agencies  and 
individuals working with the prisoner. The Community Offender Manager takes responsibility for coordinating 
the prisoner’s resettlement support, addressing and escalating any concerns relating to risk, and undertaking 
any required  pre-release risk assessments, including  OASys, a risk assessment  conducted by  the Community 
Offender Manager at various stages of the prisoner’s time in custody.   Where a prisoner is recalled to custody 
their  case  management  is  the  responsibility  of  the  Probation  Service  Community  Offender  Manager  with 
support from the prison based Prison Offender Manager. 

2 

Client Confidential 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Prior  to  release,  the  Community  Offender  Manager  must  review  the  OASys  assessment  and  prepare  a  pre-
release  report/assessment  of  the  prisoner  using  the  OASys  tool.    This  should  place  particular  focus  on 
resettlement needs and further actions required to safeguard against any concerns regarding potential risks of 
causing harm and/or of reoffending. 

Further Action 

Prior to conclusion of the inquest touching the death of Mr Billington, G4S had the opportunity to participate 
in  and  consider  the  outcomes  of  the  NICHE  report  commissioned  by  the  NHS,  and  a  MAPPA  serious  case 
review, two detailed investigations into the material incident. No recommendations were made relating to G4S 
in respect of the discharge from prison in either of the reports, however, G4S carefully noted the findings and 
carefully noted evidence provided at the inquest touching the death of Mr Billington. 

Having considered the two investigation reports and  having listened to the evidence, steps have been  taken 
by G4S at HMP & YOI Parc to reinforce information sharing and communication surrounding the release of a 
prisoner from custody.   

•  Resettlement  services  drop-in  sessions  have  been  introduced  and  approved  laptops  have  been  received 
from  HMPPS  to  roll  out  remote  sessions  under  resettlement  activities,  to  encourage  engagement  with 
resettlement  services  by  prisoners  approaching  release  and  to  provide  opportunities  to  gather  further 
information.   

•  Monthly strategy meetings at the prison show consistently high (c 90%) levels of prisoners released from 
custody are housed on the first night of their release, so that their whereabouts immediately post release 
is known to relevant community services. 

•  At HMP & YOI Parc, a member of the cashiers team issues a travel warrant for each prisoner shortly before 
they  are  released  from  custody.  The  cashier  previously  recorded  on  CMS,  the  prison’s  central  electronic 
messaging  system,  the  fact  that  a  travel  warrant  had  been  issued.  The  cashier  now  records  where  the 
travel  warrant  has  been  issued  to,  and,  in  addition,  sends  an  email  to  a  new  OMU  email  group,  which 
includes healthcare admin and the Heads of Offender Management, to indicate that a travel warrant has 
been  issued  with  details  of  where  the  travel  warrant  has  been  issued  to.  This  email  is  automatically 
received by all offender managers within OMU.  This information is then communicated to the Community 
Offender Manager and any other individuals/agencies involved with the prisoner. 

•  Whilst Community Offender Managers have responsibility for the coordination of release planning, notice 
was  given  by  email  to  all  offender  managers  within  HMP  &  YOI  Parc  that  they  must  notify  the  relevant 
Community Offender Manager when a prisoner is being released at sentence end date and will be of no 
fixed  abode.    When  doing  so,  they  must  provide  any  information  relating  to  a  prisoner’s  intentions  in 
terms of where they are going on the day of release.  This will assist the Community Offender Manager to 
effectively  manage  the  prisoner’s  release,  and  to  coordinate  and  link  in  with  other  external  agencies 
believed by the Community Offender Manager to be relevant to coordinate interagency working. 

The  HMPPS  primary  national  electronic  records  system  used  in  all  prisons  in  England  and  Wales  is  DPS 
(formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including 
NDelius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems 
used  by  third  party  providers.    G4S  has  no  power  to  implement  changes  to  streamline  IT  systems  used  by 
HMPPS, the NHS and/or other third party providers.  Other interested persons may be better able to assist HM 
Senior Coroner in relation to this issue.  G4S will, however, continue to streamline its own data recording, to 
ensure as much information as possible is shared through the primary national prisons IT system, DPS.   G4S 
has very limited access to NDelius, but information on this system is regularly accessible to Probation Service 

3 

Client Confidential 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 staff working at HMP & YOI Parc, and Probation Service staff within the community. Any issues around sharing 
information recorded on NDelius should be addressed to HMPPS. 

We  trust  this  information  is  of  assistance  and  provides  reassurance  regarding  management  of  release  from 
custody and interagency working to the extent that G4S is able to take action. 

Yours faithfully 

Clyde & Co Claims LLP 

4 

Client Confidential

Regional Probation Director
West Midlands Probation Service
19th Floor Centre City House
Birmingham
B5 4UA

27th September 2024

Mrs. Louise Hunt 
Senior Coroner for Birmingham & Solihull 
Coroner’s Court 
Steelhouse Lane 
Birmingham B4 6BJ 

(sent by email to: 

)  

Dear Mrs. Hunt,   

Inquest into the death of Jacob Michael Nicholas Billington   

Thank you for your Regulation 28 Report, issued following the Inquest into the death of Jacob 
Billington addressed to HMPPS (His Majesty’s Prison and Probation Service). I am the 
Regional Probation Director for West Midlands Probation and am replying on behalf of 
HMPPS.   
I know that you will share a copy of this response with the family and I would first like to 
express my sincere condolences for their loss.  
You have raised the following areas of concerns to which I respond as follows:-  

1.Management of release and lack of interagency working The management of the 
perpetrator’s release was not coordinated and there was inadequate communication between 
relevant agencies. In effect agencies worked in silos. Critical information is not being shared 
and agencies work in different IT systems meaning there is no one place where information is 
collated and hence a comprehensive account of matters known to each agency is not easily 
available to those professionals who may need to know a high risk prisoner’s whereabouts on 
release. This concern was reinforced by evidence heard during the inquest that changes 
made since Jacob's death did not include resettlement information being given to Mental 
Health In reach teams in the prison. The failure to share information leads to a concern of 

www.gov.uk/probationservice 

 
 
 
 
 future deaths as high risk seriously unwell prisoners may be released without key agencies 
knowing where they are meaning they are not traced and treated assertively in the 
community.   

For a prisoner to still be detained in custody at the point of sentence expiry is usually as a 
result of them having being recalled to custody.  This means they remain the responsibility of 
the Probation Community Offender Manager (COM) until the point of release at the sentence 
end date (SED).   There is no statutory authority for Probation supervision of a prisoner 
released into the community at SED.   The sharing of information prior to release into the 
community in an effective manner with relevant agencies is therefore of paramount 
importance.  The Probation Service West Midlands has a practice document which sets out 
the expectations for Practitioners when cases are being released at SED.  This document has 
been revised and re issued to all staff and embedded in development sessions delivered by 
the Regional Quality Team.  The processes to be followed prior to release include completion 
of a termination OASys (offender assessment) risk assessment which will identify the areas of 
risk which require the sharing of information with other agencies and, if applicable, under Multi 
Agency Public Protection (MAPPA) arrangements.    
MAPP arrangements are overseen by a Strategic Management Board (SMB) and in the West 
Midlands this Board will continue to review and refine practices to ensure interagency working 
is effective and to support the sharing of relevant risk information. The findings in this case 
have been presented to MAPPA SMB.  The SMB is committed to ensuring their part in 
providing avenues to share information. Furthermore, the SMB has reinforced the statutory 
requirement for all duty to cooperate agencies in the MAPPA arena.  

2. Systmone   

Systmone is an IT system used by healthcare professionals, and is not a system that HMPPS 
can access, review or change.  

3. Cross agency guidance regarding release of high risk prisoners with mental health 
difficulties at their sentence end date There are no provisions available nor any cross 
agency guidance in place for when a high-risk prisoner is released at sentence end date to 
ensure that there is adequate release planning and maximum support in the community.  

NHS-England are commissioned to provide healthcare in Prisons. The sharing of information 
between health in custody and health in the community is a core feature of the nationally 
rolled out NHS-England Reconnect Service. West Midlands Probation Service  has actively 
promoted the Reconnect Service with Probation Practitioners in recent months to ensure they 
are aware of how to refer into this service in Prison for support “through the gate”, the 
transition period from prison into the community.    

4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the 
evidence at the inquest that this role was not fully understood by other agencies and what 
information needed to be shared was not clear. The new policy drafted by BSMHT remained 
confused as to which cases were to fall within the responsibility of the prison discharge 
coordinator role. There remains a risk of further deaths as the role is not properly understood 
and information sharing is not effective.  

2 

 
  
  
  
 The Prison Discharge Coordinator role is a Health Trust bespoke role in Birmingham and 
Solihull.  West Midlands Probation Service welcomes the investment in this role for this area 
and will work with the Health Trust to support any Guidance revisions undertaken by the 
Health Trust to ensure that the Guidance is clear and enables effective information sharing 
and can be embedded within and understood by all in the Probation Service.   
Thank you for bringing these matters of concern to my attention.  Please be assured that 
since I attended Jacob’s inquest, learning from the circumstances of this tragic death has 
been shared more widely with colleagues and will continue to inform improvements across all 
the Probation Regions.    

Yours sincerely, 

Regional Probation Director   

West Midlands Probation Service  

3

Prif Weithredwr Dros Dro/Interim Chief Executive: 

Cadeirydd/Chairman: 

gofalu am ein gilydd, cydweithio, gwella bob amser 
 caring for each other, working together, always improving 

           Rydym yn croesawu gohebiaeth yn y Gymraeg ac yn y Saesneg.  
We welcome correspondence in Welsh or English. 

Ein Cyf / Our Ref: 

Dyddiad / Date:  8th May 2024 

FAO: Mrs Louise Hunt 
Senior Coroner for Birmingham and Solihull 

Dear Mrs Hunt, 

RESPONSE BY SWASNEA BAY UNIVERISTY HEALTH BOARD TO REGULATION 28 
REPORT TO PREVENT FUTURE DEATHS ISSUED IN THE INQUEST OF J 
BILLINGTON  

Thank you for providing the Health Board with an opportunity to respond to your concerns 

raised at the conclusion of the inquest of Mr Jacob Billington. 

At  the  outset  I  would  wish  to  send  my  condolences  on  behalf  of  Swansea  Bay  University 
Health Board to Mr Billington’s family.   

In your Prevention of Further Deaths notification, you identified the following concerns and 

stated that it was your opinion that there is a risk that future deaths will occur unless action 

is taken. The Report was addressed to 5 Interested Persons and I am responding on behalf 

of Swansea Bay University Health Board. In the following, I will seek to outline what action 

we have taken to address your concerns.  

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR / Swansea Bay UHB Headquarters,  
One Talbot Gateway, Port Talbot, SA12 7BR 
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe 
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board 

  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The MATTERS OF CONCERN identified were:  

1. 

Management of release and lack of interagency working  

The management of the perpetrators release was not coordinated and there was inadequate 

communication  between  relevant  agencies.  In  effect  agencies  worked  in  silos.  Critical 

information is not being shared and agencies work in different IT systems meaning  there is 

no one place where information is collated and hence a comprehensive account of matters 

known to each agency is not easily available to those professionals who may need to know 
a  high  risk  prisoner’s  whereabouts  on  release.  This  concern  was  reinforced  by  evidence 

heard during the inquest that changes made since Jacob's death did not include resettlement 

information being given to Mental Health In reach teams in the prison. The failure to share 

information leads to a concern of future deaths as high risk seriously unwell prisoners may 

be released without key agencies knowing where they are meaning they are not traced and 

treated assertively in the community.  

Response of Swansea Bay University Health Board  

Swansea  University  Health  Board  recognise  that  there  is  not  a  shared  database  for 

interagency working in place across England and Wales prison establishments to enable the 

transfer and access to key information by agencies coordinating the discharge of high risk 

individuals.    

Swansea Bay University Health Board were, at the time of Jacob Billington’s death, providing 

Mental Health In-Reach (MHIR) services within both HMP Parc and HMP Swansea. Since 

September 2023 the Health Board now only provide MHIR services to HMP Swansea. 

Swansea Bay University Health Board does not have the  power to implement a unified IT 

System  but evidence was  provided  at  the  Inquest  regarding  the  changes  implemented by 

Swansea Bay University Health Board to include the steps taken to ensure that matters within 

their power to aid Care Coordination and discharge planning with the relevant agencies were 

established. Full details are set out below to ensure high risk, seriously unwell prisoners are 

not released without key agencies knowing where, and treated assertively in the community 

where appropriately identified.   

 caring for each other, working together, always improving 

gofalu am ein gilydd, cydweithio, gwella bob amser 

Page 2 

 
 
 
 
 
 
 
 The MHIR Team act as a provider of care whilst the individual is in custody and ensure: 

•  Formal hand over of care is received from the transferring Community Mental Health 

Team (CMHT) or previous prison via a formal meeting 

•  Formal pre-release meetings are held with CMHT or transferring prison 
•  Receive and review the Care and Treatment Plan (CTP) and Risk Assessment (RA) 

within 7 days of admission and upload onto the patient record (on SystemOne) 

•  Facilitate 6 monthly CTP review meetings 
•  Undertake CTP and RA monthly audits to ensure quality and performance  

Prisoners in HMP Swansea, who will be predominantly Welsh, will be subject to the Mental 

Health  Measure  (Wales)  2012  and  therefore  will  legally  be  required  to  have  a  Care  and 
Treatment Plan – this will be continued to be overseen by the individual’s community Care 

Coordinator and the MHIR Team working in collaboration with them to ensure care provision 

within  the  custodial  setting.  Details  of  interventions  conducted  by  the  MHIR  Team  will  be 

provided to the Care Coordinator as required or through the 6 monthly review meetings.   

In respect of MAPPA, Swansea Bay University Health Board undertake the role of a ‘Duty to 
Cooperate Agency’ with Probation, HMP and the Police as the Responsible Authority – it is 
the Responsible Authority’s responsibility to inform Health if a MAPPA eligible individual is 

scheduled for discharge and ensure we are invited to relevant meetings to coordinate release 

/  discharge  management.  The  MHIR  Team  liaise  directly  with  the  prison  based  Offender 

Management Unit and not directly with MAPPA. Liaison with MAPPA is the responsibility of 

the Offender Management Unit. 

Discharge to Community  

The MHIR Team arrange a Multi-Disciplinary Team (MDT) review meeting prior to discharge. 

Discharge planning is individualised depending on the patient’s legal status (sentenced, or 

remand).  When sentence end / release dates are known, MDT meetings are planned 4/6 

weeks prior to identified date and these meetings are now designated as Formal Pre-Release 

Planning Meetings.  

A Formal discharge meeting is also held between the MHIR and Primary Care Teams when 

patients  /  prisoners  within  the  prison  setting  are  being  discharged  from  secondary  care 

services (MHIR) back to primary care services within the prison. This meeting includes a full 

 caring for each other, working together, always improving 

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Page 3 

 
 
   
 and  comprehensive  handover  of  care  and  a  documented  discharge  summary.  These 

meetings are recorded and documented.  

The  MHIR  CPN  works  with  the  prisoner  /  patient’s  Care  Co-ordinator  by  completing  a 

recovery care plan and updating current risk assessment. If the prisoner / patient is already 

Care Co-ordinated within the community prior to incarceration then the MHIR Team become 
the co-workers, working alongside the patient’s Care Co-ordinator. This commences as soon 

as the prisoner / patient is allocated to MHIR team. The MHIR Team contact the Care Co-

ordinator and request a joint meeting to update and undertake RA and care planning.  

We recognise that robust discharge planning is essential, particularly links with local mental 
health providers, GP’s and other interested parties. This is undertaken by: 

•  Formal  pre-release  meeting  with  CMHT  /  transferring  prison  /  Probation  and  other 

agency involvement  

•  A  discharge  summary  is  completed  and  sent  to  the  GP  and  given  to  the  prisoner  / 

patient - we issue the prisoner / patient with the discharge summary if they do not have 
a GP. With the prisoner / patient’s consent we also provide the discharge summary to 

their Probation Officer  

•  The MHIR Team make contact with the prisoner / patient 14 days following discharge 

and if there is no telephone number then we cannot do the follow up phone call. We 

do rely on other agencies such as Offender Managers for updates if there is no phone 

number. If the prisoner / patient has been transferred from MHIR to a hospital then the 

team follow up with the ward following the 14 day period  

•  On a  weekly basis the  MHIR Team are  sent  the  discharge  information of prisoners 
from  the  Offender  Management  Unit  (OMU).  We  don’t  request  travel  warrant 

information as the travel warrant is only issued on the day of travel. We also now have 
access  to  the  prison  NOMIS  system  which  we  didn’t  previously  (training  for  use  is 

being rolled out to the whole team with 50% already achieved). This system is updated 

by  the  Resettlement  Team  and  OMU  regarding  release  dates.  These  layered 

approaches help to avoid the risk of the team not being aware of relevant information  
•  A Governor Grade officer now attends the MHIR Single Point of Access Meeting and 

they are able to log onto NOMIS and check the release date of each patient as they 
are being discussed, thus providing ‘live’ information to the meeting 

 caring for each other, working together, always improving 

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Page 4 

 
 
 
 Responsible Clinician role  

•  Clear documentation of capacity assessment surrounding treatment 
•  Attendance at S.117 (Mental Health Act) and CTP review meetings under the Mental 

Health Measure (Wales) requirements   

Governance   

•  The development of the MHIR Audit plan ensures processes are in place to support 

and drive improvement 

•  The  service  specification  document  /  operational  policy  have  been  updated  which 

offers detail on the function of the MHIR service 

•  An action plan is now generated from SPAM with actions monitored and recorded and 

reviewed at subsequent meetings  

•  A  MHIR  Clinical  Standards  document  has  been  developed  covering  the  following 

domains:  

1.  Referral / Admission/ Assessment 

2.  Discharge / Transfer 

3.  Patient safety / experience 

4.  Training / Continuous Professional Development /Support 

5.  Workforce / Capacity 

6.  Medicines Management  

7.  Leadership and Governance 

8.  Partnership working 

9.  Environment  

Audit findings are reported via: 

•  A  Divisional  report  presented  to  the  Mental  Health  &  Learning  Disability  (MHLD) 

Quality and Safety Committee  
•  MHLD Performance Score Card 
•  HMP Swansea Partnership Board  
•  MHLD Clinical Audit Subgroup 

New additions to the Service Group performance score card:  

•  CTP / RA monthly audit via performance score card  

 caring for each other, working together, always improving 

gofalu am ein gilydd, cydweithio, gwella bob amser 

Page 5 

 
 
 
 •  Handover of care data upon discharge (Discharge planning meetings) 
•  Number of release notification dates received from OMU  
•  Handover of care meetings upon admission  
•  6 Monthly CTP Meetings 
•  Attendance at ACCT Meetings out of number of invites (weekly) 
•  CTP’s received from community Care Co-ordinator 
•  Number of patients not engaging with MHIR / action taken 
•  Number of patients declining medication / action taken 
•  Number of Did Not Attend by patients weekly in month / reason / action taken 
•  Number of cancelled clinics in month  

There  is  also  now  improved  partnership  working  with  pharmacy  regarding  medication 

pathways  and escalation  of  concerns  in  relation  to  non-compliance.    Appropriate action is 

taken following review of circumstances of non-compliance. 

2. 

SystemOne  

Details  of  the perpetrators GP  and  local CMHT  were  not  recorded  in  an easily  accessible 

format.  The  format  in  which  key  information  is  recorded  has  now  been  amended  at  HMP 
Swansea  to  ensure  the  prisoner’s  GP  details  and  their  CMHT’s  details  (if  a  person  is  an 

existing patient under a CMHT) are highlighted on a front screen/page.  You were informed 

that this change in information management and presentation within SystemOne is unique to 

HMP  Swansea  and  is  not  the  practice  in  other  prisons.  You  were  concerned  that  there 

remains  a  risk  that  staff  treating  patients  in  prison  may  not  have  easy  access  to  (and  so 

overlook) this key information.  

Response by Swansea Bay University Health Board  

Swansea  Bay  University  Health  Board  MHIR confirmed  to  the  Coroner during  the  Inquest 

that they had implemented a change as detailed above within SystemOne - this was a local 

change. Swansea Bay University Health Board do not have the relevant system control to be 

able to implement a change to all SystemOne systems across the prison estates in England 

and Wales or to confirm what templates may already being used.  

 caring for each other, working together, always improving 

gofalu am ein gilydd, cydweithio, gwella bob amser 

Page 6 

 
 
 
 
 
 
 
 The Health Board have made contact with Product Support Centre, Digital Health and Care 

Wales advising of the Coroners Regulation 28 Report.  The Health Board will also report at 

National level to NHS Wales and Prison Health in Wales to take forward. 

The information included within this change allows direct access for local SystemOne users 

to identify the allocated MHIR worker, (if they are Care Coordinator / Co Worker or Assessor), 

whether they are known to or under a CMHT and have a Care Coordinator, their last known 

Registered GP (if known). These additions were made by the MHIR Team administrator and 
one of the MHIR CPN’s. These details are currently accessible to any Clinician working with 

/ seeing the prisoner / patient at HMP Swansea only.    

3. 

Cross  agency  guidance  regarding  release  of  high  risk  prisoners  with  mental 

health difficulties at their sentence end date.  

There are no provisions available nor any cross agency guidance in place for when a high-

risk  prisoner  is  released  at  sentence  end  date  to  ensure  that  there  is  adequate  release 

planning and maximum support in the community.  

Response Swansea Bay University Health Board  

Swansea Bay University Health Board have no jurisdiction/power over the actions required 

for this concern, but have alerted the MAPPA Coordinator to this concern and asked that it is 
raised at the local Strategic Management Board (SMB) for consideration – the Health Board 
are  a  ‘Duty  to  Cooperate  Agency’  to  these  arrangements  and  will  participate  in  SMB 

discussions. 

4. 

West Midlands MAPPA  

West  Midlands  MAPPA  has  a  prison  discharge  coordinator  role.  It  was  clear  from  the 

evidence at the inquest that this role was not fully understood by other agencies and what 

information needed to be shared was not clear. The new policy drafted by BSMHT remained 

confused  as  to  which  cases  were  to  fall  within  the  responsibility  of  the  prison  discharge 

coordinator role. There remains a risk of further deaths as the role is not properly understood 

and information sharing is not effective.  

 caring for each other, working together, always improving 

gofalu am ein gilydd, cydweithio, gwella bob amser 

Page 7 

 
 
 
 
 
 
 
 
 Response Swansea Bay University Health Board 

Swansea Bay University does not have power to take action regarding the concern detailed. 

I hope that you are assured from this response that the Health Board is taking appropriate 

measures  within  their  power  to  address  the  issues  that  were  identified  during  Mr  Jacob 
Billington’s inquest.  

Yours sincerely, 

INTERIM CHIEF EXECUTIVE OFFICER 

 caring for each other, working together, always improving 

gofalu am ein gilydd, cydweithio, gwella bob amser 

Page 8

Keeping our Communities  
Safe and Reassured 

Working in partnership, making 
communities safer 

STAFFORDSHIRE AND WEST MIDLANDS POLICE 
JOINT LEGAL SERVICES 

Director of Legal Services 

Your Ref: 

Our Ref: 

Email: 

Date: 8 May, 2024 

Dear Mrs Hunt, 

Prevention of Future Deaths report dated 13 March 2024 

I write in response to the Prevention of Future Deaths report dated the 13 March 2024 which followed on 

from  the  inquest  concerning  the  death  of  Mr  Jacob  Billington.  The  report  identified  four  key  areas  of 

concern, namely: 

1.  Management of release and lack of interagency working. The management of the perpetrators 

release was not coordinated and there was inadequate communication between relevant agencies. 

In  effect  agencies  worked  in  silos.  Critical  information  is  not  being  shared  and  agencies  work  in 

different  IT  systems  meaning  there  is  no  one  place  where  information  is  collated  and  hence  a 

comprehensive  account  of  matters  known  to  each  agency  is  not  easily  available  to  those 
professionals who may need to know a high-risk prisoner’s whereabouts on release. This concern 

was  reinforced  by  evidence  heard  during  the  inquest  that  changes  made  since  Jacob's  death did 

not include resettlement information being given to Mental Health In reach teams in the prison. The 

failure  to  share  information  leads  to  a  concern  of  future  deaths  as  high  risk  seriously  unwell 

prisoners  may  be  released  without  key  agencies  knowing  where  they  are  meaning  they  are  not 

traced and treated assertively in the community.  

2.  Systmone.  Details  of  the  perpetrator’s  GP  and  local  CMHT  were  not  recorded  in  an  easily 

accessible format. The format in which key information is recorded has now been amended at HMP 
Swansea  to  ensure  the  prisoner’s  GP  details  and  their  CMHT’s  details  (if  a  person  is  an  existing 

patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in 

information management and presentation within Systmone is unique to HMP Swansea and is not 

the practice in other prisons. I am concerned that there remains a risk that staff treating patients in 

prison may not have easy access to (and so overlook) this key information. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  Cross  agency  guidance  regarding  release  of  high-risk  prisoners  with  mental  health 

difficulties  at  their  sentence  end  date.  There  are  no  provisions available nor any cross-agency 

guidance  in  place  for  when  a  high-risk  prisoner  is  released  at  sentence  end  date  to  ensure  that 

there is adequate release planning and maximum support in the community. 

4.  West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence 

at the inquest that this role was not fully understood by other agencies and what information needed 

to  be  shared  was  not  clear.  The  new  policy  drafted  by  BSMHT  remained  confused  as  to  which 

cases were to fall within the responsibility of the prison discharge coordinator role. There remains a 

risk of further deaths as the role is not properly understood and information sharing is not effective. 

This  letter  is  the  response  on  behalf  of  the  Chief  Constable  of  West  Midlands  Police.  Given  the  issues 

identified within the report, in preparing this response West Midlands Police have liaised with HM Prisons 

and Probation Service (HMPPS). As the lead agency for the  Multi-Agency Public Protection Arrangements 

(MAPPA), I understand HMPPS will also provide a response. 

Management of release and lack of interagency working  

MAPPA is a national framework to assess and manage the risk posed by serious and violent offenders. It is 

not a statutory body in itself but is a mechanism through which agencies can better discharge their statutory 

responsibilities  and  protect  the  public  in  a  co-ordinated  manner.  Agencies  at  all  times  retain  their  full 

statutory responsibilities and obligations. They need to ensure that these are not compromised by MAPPA. 

In  particular,  no  agency  should  feel  pressured  to  agree  to  a  course  of  action  which  they  consider  is  in 

conflict with their statutory obligations and wider responsibility for public protection. 

West  Midlands  Police  are  fully  engaged  at  all  levels  of  MAPPA,  including  attendance  at  the  Strategic 

Management  Board  (SMB),  which  is  the  means  by  which  the  partnership  fulfils  its  duties  to  keep  the 

MAPPA arrangements under review. The SMB monitors the effectiveness of MAPPA, making any changes 

that appear necessary or expedient. The SMB is therefore responsible for managing MAPPA activity in its 

area.  This  includes  reviewing  its  operations  for  quality,  and  effectiveness  and  planning  how  to 

accommodate  any  changes  as  a  result  of  legislative  changes,  national  guidance  or  wider  criminal  justice 

changes. The SMB are responsible for the implementation of the MAPPA Guidance in their area, in line with 

local initiatives and priorities. WMP will ensure a senior leader is present at SMB, this will be at least a Chief 

Superintendent  and,  where  possible,  other  senior  leaders  and  the  Assistant  Chief  Constable  with 

responsibility for MAPPA will also attend. 

We will ensure that all offenders subject to notification requirements: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Register as required. 
•  Are assessed in accordance with a nationally approved risk assessment and management system.  
•  Are visited at their registered address in line with the approved Risk Management Plan (RMP) and 

national guidance.  

•  Are managed in line with approved professional practice.  
•  Are  entered  on  ViSOR  and  have  their  ViSOR  records  maintained  in  accordance  with  national 

ViSOR standards. 

The vast majority of MAPPA offenders will be managed through the ordinary management of one agency, 

although this will usually involve the sharing of information with other relevant agencies. The structural basis 

for  the  discussion  of  MAPPA  offenders  who  need  active  inter-agency  management,  including  their  risk 

assessment  and  risk  management,  is  the  MAPPA  meeting.  The  Responsible  Authority  agencies  and  the 

MAPPA Co-ordinator are permanent members of these meetings. Other agencies are invited to attend for 

any  offender  in  respect  of  whom  they  can  provide  additional  support  and management. The frequency of 

meetings depends on the level of management deemed appropriate for each offender.  

West  Midlands  Police  will  attend  all  Level  2  and  3  meetings.  The  officer  attending  the  meetings  will  be 

senior enough in rank to allocate police resources. Best practice involves attendance from an Inspector at 

all  Level  2  meetings  and  Chief  Inspector  at  all  Level  3  meetings.  However,  a  lower-ranking  officer  may 

attend where necessary if they have experience of the MAPPA process and delegated authority to allocate 

police resources at the appropriate level.  

Visor  is  the  shared  IT  system  accessible  to  numerous  agencies.  West  Midlands  Police  will  ensure  we 

continue to update Visor records for each individual to ensure information can be shared across agencies. 

We  will  work  with  all  agencies  to  understand  key  roles  and  systems  to  better  share  information,  manage 

individuals and protect the public. 

Finally, as explained in evidence during the inquest: West Midlands Police’s approach to visiting managed 
offenders has changed since Mr Billington’s death. The position now is that a West Midlands Police officer 

will  try  to  visit  a  managed  offender  when  they  are  released  from  prison,  regardless  of  the  status  of  the 

MAPPA process.  

Systmone 

As Systmone is an IT system used by healthcare professionals, West Midlands Police did not (and do not) 

have access to this system. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Cross  agency  guidance  regarding  release  of  high-risk  prisoners  with  mental  health  difficulties  at 

their sentence end date 

This  issue  will  be  addressed  by  HMPPS,  however  we  will  ensure  we  provide  support  from  a  policing 

perspective to partners in relation to high-risk prisoners with mental health difficulties at their sentence end 

date. From a policing perspective, it is important to note that the IT systems now in place (as described in 

evidence  during  the  inquest)  have  changed  meaning  that  there  are  now  better  opportunities  to  identify 

someone if they have been assessed as being at an increased risk to themselves or others. 

West Midlands MAPPA has a prison discharge coordinator role 

The issue will be addressed by the partners who manage the prisoner coordinator role and who amend the 

new policy. West Midlands Police will work with our MAPPA partners to ensure both the role and policy are 

both understood and cascaded to all staff within the police MAPPA teams.  

If WMP can be of further assistance in relation to this matter, please do not hesitate to contact me. 

Yours sincerely 

Assistant Chief Constable 

Please reply to: 
Birmingham Office: 
Joint Legal Services 
West Midlands Police,  
PO Box 52, Lloyd House,  
Colmore Circus  
Birmingham, B4 6NQ 
Tel: 0121 626 8317  

Staffordshire Office 
Joint Legal Services 
Staffordshire Police Headquarters 
PO Box 3167 
Stafford, ST16 9JZ  
Tel: 01785 232259 

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