Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0160, written 21 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Mar 2024 |
|---|---|
| Reference | 2024-0160 |
| Deceased | Alan Davies |
| Coroner | David Regan |
| Coroner area | South Wales Central |
| Category | State Custody related deaths · Wales prevention of future deaths reports (2019 onwards) |
| 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) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Governor of HMP Cardiff, The Chief Executive of the Cardiff and Vale University Health Board, the Chief Executive of the Swansea Bay University Health Board and the Secretary of State for Justice 1 CORONER I am David Regan, Assistant Coroner, for the coroner area of South Wales Central. 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 A Coronial investigation was commenced on 23rd September 2021 into the death of Alan Richard Miles Davies. The Investigation concluded at the end of the inquest which I conducted with a jury on 26th February – 15th March 2024. The conclusion was a narrative conclusion and the medical cause of death was 1 (a) Cardiac arrest in a setting of starvation and dehydration 4 CIRCUMSTANCES OF THE DEATH These were recorded as: Mr Davies was transferred to HMP Cardiff from Caswell Clinic on the 2nd September 2021. 10 days later on 12th September Mr Davies was found in a collapsed state in his cell and following CPR was transferred by ambulance to University Hospital of Wales where he later died. The narrative conclusion which the Jury returned was: Mr Davies died from an equal combination of misadventure, self neglect and neglect. Mr Davies contributed to his death by deliberately refusing food and fluid but he did not intend to end his life. It was an unintended consequence of such refusal. There were missed opportunities regarding the transfer of Mr Davies to hospital. The management, coordination and planning of Mr Davies' care including the handover of information within the prison and healthcare was unsatisfactory. The level and adequacy of observations was insufficient in noticing Mr Davies' signs of deterioration. The events between 10th and 12th September were highly unacceptable. The Inquest focused upon the following: - 1. Mr Davies was transferred to HMP Cardiff from the Caswell Clinic following 16 days of food refusal in a state in which reception nursing 1 staff felt he was unfit to be admitted to the prison, mobilising by wheelchair and requiring to be physically supported by escort staff. 2. While Mr Davies refused to consent to formal observations, no assessment was made by Caswell Clinic of his physical condition prior to his transfer. 3. No advanced notice was provided to HMP Cardiff that Mr Davies was being transferred to it in an impaired physical condition and refusing food, although the risk that he would refuse food had been communicated 4. Mr Davies was transferred to HMP Cardiff by escort agency staff unfamiliar with his care or needs 5. The majority of the Caswell Clinic discharge paperwork was provided to HMP Cardiff at the time of transfer rather the prior to it, in a format which did not easily identify the concerns related to his transfer 6. At HMP Cardiff there was no systematic care plan put in place to address Mr Davies’ food and fluid refusal or the risks of physical deterioration as a result of the same. 7. No policy was in place to guide prison healthcare staff relating to food and fluid refusal. 8. Mr Davies’ capacity was not assessed on a planned or formal basis in prison. 9. The prison GP reversed her decision to send Mr Davies to hospital on 10th September 2021 following discussion with a prison Governor, the product of which was that she received an erroneous understanding of the length of time for which he had been refusing food. 10. No clear plan for escalation of care was put in place for the weekend. A GP was not asked to review Mr Davies over the weekend. 11. The Health care assistant responsible for the care of Mr Davies on the night of his collapse had not been informed that he was refusing fluids and had not been observed to drink fluid since 3rd September 2021. 12. The Nurse and Health care assistant responsible for the care of Mr Davies at the time of his collapse had not been informed that he was at risk of sudden collapse due to food and fluid refusal. 13. The number of healthcare staff working night shifts was insufficient to meet the demands upon them. 2 14. Despite being held in a camera call on the Healthcare wing, Mr Davies’ focalised requests for “help” while lying on the floor of his cell were not recognised or heeded from 00.19 on 12th September 2021 until it was identified that he was in a collapsed state at about 02.54 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 is taken. In the circumstances it is my statutory duty to report to you. For your information the MATTERS OF CONCERN are as follows: (1) There was limited communication between the Caswell clinic and HMP Cardiff following the s 117 meeting until Mr Davies’ discharge. In particular, information that Mr Davies had commenced food refusal following the s 117 meeting and that it had not been possible to assess him physically prior to transfer was not clearly communicated to HMP Cardiff before the transfer occurred (2) Discharge information and assessment was not provided to HMP Cardiff in a clear and easily understandable format to manage the known risks associated with the transfer of Mr Davies to prison (3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff. Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner (4) Insufficient consideration was given to whether Mr Davies’ needs were too complex to be met by HMP Cardiff. (5) Mr Davies was transferred to HMP Cardiff with the intention that he be transferred again within a short time to HMP Parc. Insufficient consideration was given as to whether Mr Davies’ needs were better met at an alternative specialist institution. (6) No clear plan to promote Mr Davies’ engagement with prison medical services, or the assessment of his mental or physical condition was devised or implemented at HMP Cardiff (7) No clear plan for the assessment of Mr Davies’ capacity to refuse food or fluid was devised or implemented at HMP Cardiff (8) No food and fluid refusal policy was in place to guide healthcare staff. 3 (9) The number of GPs working in HMP Cardiff was insufficient to meet the demands upon them. (10) The Nurse and Health care assistant responsible for Mr Davies on the night of his collapse were working an 11.5 hour night shift without rest breaks, which they identified as being overly fatiguing (11) The Nurse, Health care assistant and Custodial manager responsible for Mr Davies on the night of his collapse were not provided with clear information regarding the duration of his fluid and food refusal or the warning signs to consider in the context of the known risk of sudden collapse (12) The Health care assistant caring for Mr Davies overnight overheard more senior prison staff stating that they would not return to assist Mr Davies in healthcare, and felt unable to challenge this. 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 17th May 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 following who may find it useful or of interest. Mr Davies’s family, HM Prison and Probation Service, the Governor of HMP Parc, the Medical Director of the Cardiff and Vale University Health Board, Medical Director of the Swansea Bay University Health Board. 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 21st March 2024 SIGNED: D Regan Assistant Coroner 4
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.
Minister Helen Whately Minister of State for Care 39 Victoria Street London SW1H 0EU 15 May 2024 Lauren Costello HM Assistant Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Costello, Thank you for your letter of 12 March 2024 to the Secretary of State for Health and Social Care about the death of Peter Beresford. I am replying as Minister with responsibility for urgent and emergency services. Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Beresford’s death and I offer my sincere condolences to his family. It is vital that we learn from incidents, where they are identified, to improve NHS care. I am grateful to you for bringing these matters to my attention. You have appropriately shared your report and concerns with NWAS who are best placed to respond on the specific actions being taken locally to improve ambulance response times. I note the measures the trust has said are being taken to improve performance, as set out in your report, including the ongoing recruitment of staff and also that performance regionally has been improving. As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this year. The plan is available at https://www.england.nhs.uk/wp- content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care- services.pdf Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly. I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is 1 why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads. Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings. At a national level, we have seen significant improvements in performance this year compared to last year. In 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13 minutes faster compared to the previous year, a reduction of 27%. NWAS average Category 2 response times were also over 13 minutes faster in 2023-24 compared to the previous year, a 32% reduction. In March 2024, average patient handover time in the NWAS region was 32 minutes 51 seconds, and the second month in a row that times have improved (information on ambulance handover times has been published since October 2023). However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this. Thank you once again for bringing these concerns to my attention. Yours, HELEN WHATELY
• HM Prison & Probation Service Mr David Regan HM Assistant Coroner for South Wales Central The Coroner's officer The Old Courthouse Courthouse Street Pontypridd CF371JW Dear Mr Regan, Director General of Operations HM Prison and Probation Service Slh Floor Ministry of Justice 102 Petty France London SW1H 9AJ 17 May 2024 Thank you for your Regulation 28 report of 21 March 2024, addressed to the Governor of HMP Cardiff, the Chief Executive of the Cardiff and Vale University Health Board, the Chief Executive of the Swansea Bay University Health Board, and the Secretary of State for Justice. 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 Davies' 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 expressed several concerns regarding the management of Mr Davies' complex needs and the communication between different parties throughout his time at the Caswell Clinic and following his transfer to HMP Cardiff. I will be responding to the issues that are for HMPPS. During the inquest, evidence described limited communication between the Caswell Clinic and HMP Cardiff following the Section 117 meeting and up until Mr Davies' discharge. It is vital that prisons receive accurate and current information regarding a prisoner's mental and physical health status so that appropriate decisions can be made with regards to their location. The Secretary of State can order the return of an individual to a prison if the responsible psychiatrist decides that the individual is no longer in need of medical treatment or that no effective treatment for the disorder can be given at the hospital to which he has been transferred to, as directed in PSI 50/2007 Transfer of Prisoners To and From Hospital Under Sections 47 and 48 of the Mental Health Act 1983. It is HMPPS' duty to serve the public by keeping in custody those committed by the court. Therefore, if it is determined by healthcare colleagues that an individual is medically suitable to return to custody and that their needs would not be met at an alternative specialist institution, then HMPPS must accept that individual. HMPPS cannot override any clinical decisions made by healthcare colleagues. I have received assurance from the Governing Governor at HMP Cardiff that all prisoner-facing staff, including both operational and healthcare colleagues, are aware of the importance of using emergency medical codes via the radio system, which will alert and summons both medical and operational staff to the scene they are required to attend. The Governing Governor is also committed to encouraging an environment in which all staff, including those who are not directly employed by HMPPS, feel able to raise concerns about an individual's management and will discuss with the Head of Healthcare how healthcare staff can be empowered to do so in accordance with Prison Service Instruction 16/2015 Adult Safeguarding in Prison. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter. Yours sincerely, Director General of Operations
Executive Headquarters / Pencadlys Gwelthredol Bwrdd lechyd Prifysgol Caerdydd a'r Fro Cardiff and Vale University Health Board CF14 4HH Woodland House Maes-y-Coed Road Cardiff Ty Coedtir Ffordd Maes-y-Coed Caerdydd CF14 4HH Chief Executive 17 May 2024 Private and Confidential Ms D Regan Assistant Coroner Coroner's Office The Old Courthouse Courthouse Street Pontypridd CF371JW Dear Mr Regan Thank you for your email dated March 22, 2024, containing the Regulation 28 and its associated improvement actions following the tragic and premature death of Mr. Alan Richard Miles Davies. I accept that whilst the conclusion was narrative, there are measures that should be taken by the Health Board and other relevant parties to mitigate the risk of similar incidents in the future. Your investigation highlighted that better communication among stakeholders could have reduced some risks. Moreover, considering the appropriate setting to address both the physical health needs and judicial requirements would have been advantageous. It is evident that during Mr. Davies' time at Cardiff HMP, there was a lack of awareness among staff regarding the assessment of mental capacity and the ability to make informed decisions regarding not accepting food or fluids. As advised at the inquest several measures had already been implemented post this tragic event. Enhanced Communication Pathway Preceding Hospital Transfers to Cardiff HMP Regarding communication pathways, collaborative efforts with relevant parties have led to the development of a Standard Operating Procedure (SOP) for transferring individuals with mental/physical health needs into our care. This SOP delineates the necessary information required by HMP Cardiff to assess the individual's health needs and outlines a organisations to mitigate information-related risks. The protocol also identifies ma ~ information across reliable route for sharing Bwrdd lechyd Prifysgol Caerdydd a'r Fr0 yw ~w gwetthredol 6wyrdd techyd Lie~ Prif-,5901 Caerdy6d a'r Fro Cirdaff ~o V-tlt vn,vef"5ety Hn'ttl, Board •s the operabonal name or Cardiff and VM Univers1tv Local t1ealth Board Croo-"' y8""10 - lh )"I G,mtN9 ,_SNstle11,-,, byddwny,,<J'_,,rebu • di/ y,,Kh-ioifh. NifyddgolrebU )"IGymnotg )"l<nJU"""'l'W°""' Tl'Nt Bcwd welcome, a:wespondence In Welsh orEngilsh. Wi, enwr. IJtet we wif oommunltele ir, )l'Ot.&" Cllosen ""9t,,,g,e. ColN$,/)Ol)(Hftetl kt Wert.sh will not JeMJ l!ll • d9lay 111:iconfident IEMPl.OVII the appropriate personnel from a healthcare perspective to attend the 117 meeting prior to transfer and specifies the information to be gathered during this meeting. This pathway provides details as to the level of information required by HMP Cardiff to be able to assess if the Healthcare Team can meet their health needs. It also describes information can be shared reliably across organisations, to mitigate any risks in relation to receipt of information. the route by which The protocol also provides guidance as to what should be considered in deciding where a person should be placed post hospital treatment i.e. whether they should be returned to the HMP from whence they were originally referred or whether a temporary placement in a local remand facility is required as an interim step. Improved Management of Communication Regarding Complex Hospital to HMP Transfers and Care Planning Following the incident, governance arrangements within HMP Cardiff have been restructured to align all healthcare staff under the same framework as the University Health Board. A Head of Healthcare is in post who is overseeing operational management. These changes have streamlined communication channels among professionals within HMP, with enhanced daily briefings incorporating information on planned transfers and individuals with complex needs. These changes mean that communication channels across the various professionals in HMP are more seamless. In addition, the daily team briefing meeting held throughout the week have been enhanced to include information on planned hospital transfers and/or any people with complex needs. On a Friday, these meetings provide an opportunity for ensuring continuity of care for patients in the Healthcare Unit over the weekend, including requests for additional medical review, where required. These meeting are attended by GPs, Nurses, Healthcare Support Workers, and Pharmacy staff. Improvements in Staff Skills in Identifying the Deteriorating Patient Since September 2021, there has been a shift in the Healthcare Team's skill mix, with the appointment of more nurses possessing general medical skills. These nurses are better equipped to identify and respond to patients at risk of deterioration. Training initiatives, including basic life support and mental capacity assessment, have been implemented, supported by a Practice Development Nurse. Additionally, a bespoke training program for Prison Nurses in Wales has commenced. in May 2024. The importance of accurate record keeping enhancing the communication has been emphasised with all staff. Policies and Procedures A Joint Food and Fluid Refusal Policy is in place at HMP Cardiff, with training provided to healthcare and prison staff. Efforts are underway to develop electronic templates supporting the policy's application. Training on Mental ~mm~~- llt'il caifldent EMPLOYEI ~~~~l';"~:~C::Vadltdha.;:,::isth~;~:~:_~~~:7~!~:;;:n~~:ri.%~!~~,e~~t;;~=~Board C t o e -y - - . io, , , ,G - neu Soo,neg. Siat>ownb,,-n)Tl<yfo/ll<ol)uf<lv)Tlekh dewis ;,;th. Ni lyddgo/lobu)TI G)fflt1109)TICl94J unrhywoe</i n,,. 9oetd•lkomt.scon - .~ in W.i:sh orEng6sh. W• tlfileMUtW thal we d~ t • 1rt )"Ot#'mos.n tangu.- Comt~bt W.ish dnol 1-«lto • del•y Capacity Assessment has been imparted to medical staff, with plans for annual updates. General Practitioner (GP) Establishment Efforts to address GP recruitment challenges include increased funding to expand the core GP establishment and the initiation of a Service Level Agreement with a local GP Practice. Additional GPs have been recruited to support current Vacancies Nursing Establishment/Working Patterns Despite national ongoing nursing shortages, strategies such as employing agency nurses with prison experience and introducing new roles like Pharmacy Technicians have been undertaken. Plans to employ a second Registered Nurse for night shifts are hindered by recruitment challenges but remain a priority. Changes to the night shift pattern are being implemented to alleviate staff workload. All new staff are employed on the basis on a 4 night/3-day rota, to reduce the need for staff to work 7 nights in a row. As explained at the inquest, the historical shift pattern inherited when the Healthcare Team transferred to the UHB (University Health Board) responsibility in 2013, has been difficult to change because staff wanted to retain this shift pattern and had some employment rights as part of the TUPE Transfer of Undertakings (Protection of Employment). With changes in nursing staff, we are now able to change the working pattern as we move forward. Management of Escalating Concerns Finally, the ability regarding of unregistered staff to raise concerns in respect of any aspect of patient care or operational matters, all staff have been reminded that they can escalate concerns to the Registered Nurse in charge on Duty or Head of Healthcare at any time. Yours sincerely Chief Executive Bwl'dd Jed'lyd Prifysgol Caerdydd a•r Fro yw enw 9we1thre001 8wyrdd lechyd Lleol Prifysgol Caetdydd a'r Fro Card~tf al'ld Vale \Jnlve~ty Health Board •s the operauonal name of Card,ff and Vale Univers,ty Local Heailt.n Board ero.uwir y 8wtddohebiaolh yn G~ ne11 s...sn.o,. Sieth.twn byddwn yn t:yfatlnbu 4 dw yn eir;h dewis flllh. Ni fydd gio,tte,bu)'11 Gym,aeg yn cntu unrl'Jyw oo,di The 8oerd wolc:omt.s c:orr..spondtnc• .., Welsh OI E"(JIWt. W• wll.,,S&,ff,,.. WII c:omtrltlf1bl•#t your chouf'I~ . e a , , .~ . , W,Nh d nol JHd lo • ~ y
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