Benjamin Harrison

OFFICIAL

Director General Operations 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London  
SW1H 9AJ 

Patricia Harding HM Senior Coroner  
Mid Kent and Medway Coroners' Service  
Oakwood House  
Oakwood Park  
Maidstone  
Kent  
ME16 8AE 

Dear Ms Harding 

October 2024 

Thank you for your Regulation 28 report of 19 July 2024 addressed to the Governor of HMP 
Rochester, following the inquest into the death of Benjamin Noah Frances Harrison on 10 
May 2022 at HMP Rochester. I am responding as Director General of Operations for His 
Majesty’s Prison and Probation Service (HMPPS). 

I know that you will share a copy of this response with Mr Harrison’s family, and I would first 
like to express my condolences for their loss. Every death in custody is a tragedy and the 
safety of those in our care is my absolute priority. 

Following evidence heard at the inquest, you have raised concerns about the appropriate 
monitoring of prisoners suspected to be under the influence of illicit substances during the 
night state and that prison staff were not sufficiently briefed about prisoners keeping 
medication in their possession. You have also raised a concern in relation to healthcare 
staff sharing relevant medical information with prison staff. I note that you have also 
addressed your report to Oxleas NHS Foundation Trust and therefore I will only be 
responding to the first two concerns as these relate to prison responsibilities. I am grateful 
to you for bringing your concerns to my attention. 

You have expressed concern that there does not appear to be a clear process at HMP 
Rochester for escalating concerns when prisoners appear to be under the influence of an 
illicit substance outside of the hours in which healthcare staff are present. I have received 
assurance from the Governor of HMP Rochester that following the inquest an order has 
been issued to all staff setting out that at times when there is no on-site healthcare team, 
such as during the night state, prison staff must escalate concerns about prisoners 
suspected to be under the influence of illicit substances to the Orderly Officer. The Orderly 
Officer will then attend to conduct a welfare check on the prisoner. Although the welfare 
check is not a medical check, if there are any concerns for the wellbeing of the prisoner the 
Orderly Officer will make a decision on whether to contact the on call doctor service or the 
emergency services. The briefing also confirmed that any welfare checks undertaken and  
requirements for further checks and/or follow up action must be recorded in the wing 
observation book to ensure that relevant information is available to all staff on the wing. 

OFFICIAL

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL

HMPPS is currently developing national guidance for all staff managing prisoners who are 
under the influence of illicit substances. The guidance has been developed by the national 
Substance Misuse Group with contributions from internal and external stakeholders, 
including from areas such as health and safety. Its purpose is to provide structured 
guidance for prisons to support the development of local under the influence guidance that 
will ensure that there is a consistent and safe response to the management of prisoners. It 
is important to note that this guidance does not replace healthcare advice and in a medical 
emergency instructions and advice from healthcare colleagues must be followed as a 
priority. The guidance is currently in the consultation stage, and while I am hopeful that this 
will go live by the end of the year this will be dependent on what the consultation identifies 
and whether further changes are required.  

Once agreed, the guidance document will be rolled out via the regional and local drug 
strategy leads who will be responsible for developing local guidance. The Substance 
Misuse Group will deliver additional training and support if necessary, and through their 
rolling programme of support assurance checks will be conducted to ensure that under the 
influence guidance has been developed and embedded at each prison. 

You have also raised a concern that night staff did not receive a briefing about prisoners 
who had medication in their possession. I have been informed by the Governor that the 
prison is working with the healthcare provider to embed a process for sharing relevant 
information about at risk prisoners who have medication in their possession. This will 
include time to discuss in possession medication at the weekly safety intervention meeting 
where complex and high risk prisoners are discussed by a multi-disciplinary team including 
prison and healthcare managers. 

Oxleas will be providing a separate response to address the action that they are taking in 
relation to healthcare staff and their understanding of what information should be shared 
with prison staff. However, I wish to assure you that the prison will fully support healthcare 
colleagues to improve relevant information sharing around in-possession medication, 
particularly during the night state.  

Thank you again for bringing your concerns to my attention. I trust that this response 
provides assurance that action is being taken to address the matters you have raised. 

Yours sincerely 

    Director General Operations 

OFFICIAL

Pinewood House
Pinewood Place
Dartford
Kent
DA2 7WG

12 September 2024

Case 

Private & Confidential

Patricia Harding
HM Senior Coroner Mid Kent and Medway
Mid Kent and Medway Coroners’ Service
Oakwood House
Oakwood Park
Maidstone
Kent
ME16 8AE

Dear Madam,

Regulation 28 Report to Prevent Future Deaths – Inquest touching the death of Mr Benjamin
Harrison

Thank  you  for  your  regulation  28  report  to  prevent  future  deaths  dated  19th  July  2024
following the inquest into the death of Mr Benjamin Harrison which concluded on 3rd June
2024.

In advance of responding to the specific concerns raised in your report, I would like to express
my deep condolences to Mr Harrison’s family and loved ones. Oxleas NHS Trust is keen to
assure the family  and the coroner that the concerns raised  about Mr Harrison’s  care have
been  listened  to  and  acted  upon.   I  appreciate  that  responses  to  Coroner  Reports  may
constitute an important part of process through which family and friends come to terms with
the passing of their loved  one, and that this will have been an incredibly  difficult time for
them.

In your paragraph 7 letter you raised concerns in relation to the care provided to Mr Harrison
whilst at HMP Rochester, namely:

1. Evidence was given by prison staff that it was not uncommon for prisoners to be

under the influence of substances, particularly spice at HMP Rochester.

 During  the  day  when  it  was  suspected  that  someone  was  under  the  influence,
healthcare would attend to assess whether medical attention or monitoring was
required, there was however no access to in house health care during the night
state.
OSG  officers  without  medical  training  or  knowledge  of  the  prisoner's  medical
history  had  to  use  their  own  judgement  whether  to  monitor  a  prisoner  or  to
escalate the matter.
The prison orderly was not notified immediately when someone appeared to be
under the influence and that the individual was thought to be under the influence
was not documented.
Prison  staff  did  not  have  any  guidance  or  policy  to  assist  them  as  to  when  to
escalate  matters  or  what  monitoring  should  be  undertaken  and  staff  did  not
routinely use the GP on call service for advice.

2. Prison  staff  did  not  receive  a  briefing  about  prisoners  with  medication  in

possession in accordance with PS24/2011.

3.

In  evidence  there  were  discrepancies  between  the  policies  in  place  and  the
understanding  of  healthcare  staff  as  to  what  information  could  be  shared  with
prison staff and when it should be shared.
Some  healthcare  staff  in  evidence  indicated  they  would  not  share  information
about medication in any circumstances.
The healthcare policy and practice of healthcare staff in relation to information
sharing does not align with PSI64/2011 that information can be shared without a
prisoner's consent if it is considered necessary to protect the individual or anyone
else from the risk of death or serious harm.
There was no clear process as to how or where the information would be shared
and  recorded either where a  prisoner  had  consented to information  sharing  or
where consent had not been given but it was nevertheless necessary to share the
information.

In addition to the above concerns, you have also clarified in your email dated 29th August the
following:

In many inquests including this it is apparent that witnesses either do not know of or
do not follow policy and in some instances, there are no policies/mechanisms in place.
In relation to this inquest in particular one of the concerns was that there was no in
house healthcare in this prison after 9pm whereas there is in many but not all other
prisons. Whilst there are mechanisms for seeking external help in the context of the
evidence in this case that was significant.

Following  the  inquest  senior  leaders  from  Oxleas  NHS  Foundation  Trust  have  considered
these helpful observations and have responded to each of your concerns as follows:

1. HMPPS  colleagues  have  responsibility  for  reducing  demand  and  supply  of  drugs  in
prisons, and there is a Governor responsible for Drug Strategy at the prison. The Drug
Strategy meeting is attended by healthcare and issues including trends of use of drugs

 such as  psychoactive substances ‘spice’  are explored.  Change,  Grow, Live (CGL) are
subcontracted by Oxleas to provide psychosocial substance misuse and they have a
large  caseload  at  HMP  Rochester  who  undertake  group  and  1:1  work  to  address
substance misuse issues including the use of psychoactive substances, and encourage
harm minimisation and ultimately recovery. Healthcare attend those suspected to be
under the influence of  substances during the day until 21:00 as  contracted  by NHS
England.  As  a  Category  C  Prison,  Rochester,  in  accordance  with  most  Category  C
prisons  does  not  have  24-hour  healthcare  provision.  The  contracts  for  Category  C
prisons do not normally make provision for healthcare services at night if there is no
Inpatient  department,  and  therefore  no  prisoners  requiring  24-hour  healthcare
provision.  NHS England would need to be asked to account for their commissioning
decision arrangements if it is felt that 24-hour healthcare is necessary in Category C
Prisons  due  to  patient  safety  risks  emerging  from  increased  use  of  drugs  such  as
psychoactive  substances,  despite  the  fact  that  these  substances  should  not  be
available in prisons.

OSG  officers  have  undergone  basic  first  aid  training  during  their  induction  to  the
standard  deemed  by  HMPPS  appropriate  for  their  roles,  including  being  in  service
during night patrol without healthcare staff on site, and managing any situation which
may  occur.  HMPPS  colleagues  will  be  able  to  give  further  details  regarding  this
training. The OSGs work together with Orderly Officers who have additional training
and  experience,  and  they  have  operational  procedures  to  follow  in  the  event  of
prisoners  who  present as  requiring medical support during night state. The  agreed
arrangements between the hours of 21:00 – 07:30 when there is no commissioned
healthcare provision on site, is that all higher risk prisoners have an agreed personal
management plan in accordance with the Personal Management Plan Local Operating
Procedure, and that in the event that officers have any healthcare concerns regarding
a prisoner the Custodial Manager in charge of the prison should call the On-Call GP for
further advice and guidance, and in an emergency they should dial 999 for emergency
services. A review of out of hours calls to the out of hours GP service will be carried
out in Autumn 2024 to ascertain frequency and effectiveness of use. Any calls to out
of hours GP are discussed in the Governor’s morning briefing each day and followed
up by the healthcare team.

2. The  guidance  states  that  “during  the  night  state  Prisoners  who  are  ‘at  risk’  are
observed, managed, supported and information and actions are recorded. Night staff
must receive a clear verbal briefing on any prisoners who are identified to require a
higher level of individual observations than normally required (such as those on an
open, or, post closure Assessment Care in Custody and Teamwork (ACCT) plan (check
and  be  directed  by  individual  plans),  or  other  prisoners  on  a  higher  than  normal
observation  level  for  other reasons  such  as  E-List,  high  security  risk,  or  medication
purposes).  The  briefing  should  also  include  information  about any  prisoner  with
medication in possession or where healthcare staff will have to administer medicines
dose  by  dose  throughout  the  “Night  State”.  Staff  must  record  their  actions  on  the
Night  Occurrence  Sheet  and  other  relevant  documentation  such  as  an  open  ACCT
plan.”

 This guidance is that the clear verbal briefing should include all prisoners who are ‘at
risk’, and not all prisoners. It would not be possible to include all prisoners who have
medication in possession in a nightly verbal briefing when up to a third of the total
population  are  prescribed  In  Possession  medication.  It  would  not  be  practical  and
could distract from the prisoners who are at risk, and who require inclusion in the clear
verbal  briefing  to  ensure  safety.  We  have  agreed  with  prison  colleagues  that
healthcare  will  share  relevant  information  within  the  weekly  Safety  Intervention
Meeting and discuss men with in-possession medication who may be at risk, so that
prison  managers  responsible  for  those  individuals  are  aware  of  any  prescribed
medication that may inform any risk management decisions. Being in-possession of a
fentanyl  patch  is  included  within  this  criteria,  and  I  can  confirm  that  there  are  no
prisoners at Rochester prescribed a fentanyl patch.

3. To  support  addressing  understanding  of  policies,  we  have  a  new  Practice
Development Nurse  (PDN) joining the team  in September 2024, to ensure that the
healthcare team are up to date with all relevant training and guidance. The PDN will
share the clear guidance set out in chapter 2 of PSI 64/2011 and ensure via teaching
sessions, read-and-sign procedure and supervision that this guidance is understood
and  followed  by  the  nursing  and  wider  healthcare  team.  There  are  mechanisms  in
place to share relevant safety and risk information on NOMIS, and this would have
included sharing information of the risks of misusing a Fentanyl patch.

Our  Quality  Manager  has  very  recently  reviewed  all  policies,  updated  them  to  the
latest  versions  and  shared  their  location  with  all  staff.  Our  PDN  will  have  the
responsibility of ensuring that the healthcare team are aware of all relevant policies,
that  they  understand  the  policies  and  the  importance  of  following  them,  and  that
these  are  shared  and  discussed  in  teaching  sessions,  handovers,  and  supervisions.
Training records will be kept in order to evidence this.

As  stated,  there  is  no  in-house  healthcare  in  HMP  Rochester  after  9pm.  There  are
arrangements for GP on-call provision arranged by providers which we have in place
at  HMP  Rochester.  GPs  on  an  on-call  rota  have  access  to  SystmOne  records  and
therefore access to past medical history, past and current medical problems and any
future  appointments  is  in  place  to  provide  medical  advice  to  prison  staff,  prevent
unnecessary transfers to hospital and ensure patient safety by providing guidance on
next  steps  when  hospital  transfer  is  required.  We  will  ensure  that  this  guidance  is
updated and that it also includes the relevant information to manage the expectations
of  HMPPS  colleagues  –  for  example  if  any  patient  monitoring  is  required  then  this
cannot be undertaken at HMP Rochester when there are no healthcare staff on site
and in any circumstances where a patient requires monitoring then they would need
to be transferred to hospital.

I hope that this letter reassures you that Oxleas has been highly attentive to the findings of
your investigation, and that concerted remedial action has been taken on all the areas you
identified to prevent any similar future deaths.

 Please do not hesitate to contact me if any clarification or further assurance is required.

Yours sincerely,

Chief Executive Officer

CC:
Chief Operation Officer, 
Chief Nursing Officer,