Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0541, written 11 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Oct 2024 |
|---|---|
| Reference | 2024-0541 |
| Deceased | Oliver Davies |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Mental Health related deaths · State Custody related deaths · Suicide (from 2015) |
| Organisation named | Midlands Partnership University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
, Chief Executive, Midlands Partnership NHS Foundation Trust,
St. George’s Hospital, Corporation Street, Stafford ST16 3SR.
1
CORONER
I am David Donald William REID, HM Senior Coroner for Worcestershire.
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 16 January 2023 I commenced an investigation and opened an inquest into the
death of Oliver Peter DAVIES. The investigation concluded at the end of the inquest
on 11 October 2024
The conclusion of the inquest was as follows:
Oliver Davies died as a result of suicide.
[ Questionnaire ]:
1.
(a) During Oliver's time at HMP Hewell, were sufficient steps taken to ensure
a proper and timely review by a GP of Oliver's mental health needs, and
whether mental health medication should be re-prescribed to him?
NO
(b) If your answer to 1(a) above is YES or CANNOT SAY, go to Question 2;
(c) If your answer to 1(a) above is NO, did that failure probably cause or
contribute to Oliver's death on 31 December 2022?
YES
(d) If your answer to 1(c) above is NO or CANNOT SAY, did that failure
possibly cause or contribute to Oliver's death on 31 December 2022?
YES/NO/CANNOT SAY
(e) If your answer to 1(d) above is NO or CANNOT SAY, please include the
following words at the end of Section 3 of the Record of Inquest: 'It is admitted
that the fact that Oliver was not seen by a GP in the prison before his death
represents a failing in the healthcare system provided there. It cannot be
concluded that this failing possibly caused or contributed to Oliver's death on
31 December 2022.
2. (a) Was information relevant to Oliver's recent and current mental state
shared sufficiently between prison staff, healthcare staff and mental
healthcare staff at HMP Hewell, such that Oliver's ongoing risk of self-harm of
suicide could be properly assessed?
NO
(b) If your answer to 2(a) above is YES or CANNOT SAY, go to Question 3;
1
(c) If your answer to 2(a) above is NO, did that failure probably cause or
contribute to Oliver's death on 31 December 2022?
YES
(d) If your answer to 2(c) above is NO or CANNOT SAY, did that failure
possibly cause or contribute to Oliver's death on 31 December 2022?
YES/NO/CANNOT SAY
3. (a) Did the mental health assessment on 6.12.22 consider sufficiently all
information relevant to Oliver's ongoing risk of self-harm or suicide?
YES
(b) If your answer to 3(a) above is YES or CANNOT SAY, go to Question 4;
(c) If your answer to 3(a) above is NO, did that failure probably cause or
contribute to Oliver's death on 31 December 2022?
YES/NO/CANNOT SAY
(d) If your answer to 3(c) above is NO or CANNOT SAY, did that failure
possibly cause or contribute to Oliver's death on 31 December 2022?
YES/NO/CANNOT SAY
4. (a) Did the ACCT case review of 30.12.22 consider sufficiently all information
relevant to Oliver's ongoing risk of self-harm or suicide?
NO
(b) If your answer to 4(a) above is YES or CANNOT SAY, go to Question 5;
(c) If your answer to 4(a) above is NO, did that failure probably cause or
contribute to Oliver's death on 31 December 2022?
NO
(d) If your answer to 4(c) above is NO or CANNOT SAY, did that failure
possibly cause or contribute to Oliver's death on 31 December 2022?
YES
5. (a) Was Oliver kept sufficiently informed of progress regarding his applications
for a doctor to review his mental health needs and to consider whether mental
health medication should be re-prescribed to him?
NO
(b) If your answer to 5(a) above is YES or CANNOT SAY, go to Question 6;
(c) If your answer to 5(a) above is NO, did that failure probably cause or
contribute to Oliver's death on 31 December 2022?
YES
(d) If your answer to 5(c) above is NO or CANNOT SAY, did that failure
possibly cause or contribute to Oliver's death on 31 December 2022?
YES/NO/CANNOT SAY
6. (a) Was Oliver kept sufficiently informed of his allocation to, and forthcoming
appointments with, a mental health care-coordinator?
NO
(b) If your answer to 6(a) above is YES or CANNOT SAY, go to Question 7;
(c) If your answer to 6(a) above is NO, did that failure probably cause or
contribute to Oliver's death on 31 December 2022?
YES
(d) If your answer to 6(c) above is NO or CANNOT SAY, did that failure
possibly cause or contribute to Oliver's death on 31 December 2022?
YES/NO/CANNOT SAY
2
7. Was Oliver's death contributed to by neglect?
YES
4
CIRCUMSTANCES OF THE DEATH
In answer to the questions “when, where and how did Oliver come by his death?”, the
jury recorded as follows:
“Oliver Davies committed suicide in his cell at HMP Hewell by hanging. He died on the
31.12.22.”
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.
The MATTERS OF CONCERN are as follows. –
1) Oliver had been at HMP Hewell since 20.10.22. He was a man with long-
standing mental health issues, for whom this was a first experience of
custody. After a steady deterioration in his mental state, a mental health
referral on 17.11.22 led to a belated mental health examination conducted by
a registered learning disability nurse on 6.12.22. In the week leading up to the
nurse’s assessment:
(a) A prison officer had made an urgent TAG mental health referral on
30.11.22, citing concerns that Oliver was experiencing active thoughts of
self-harm or suicide, and that he ( the officer ) had “mild concerns” about
intentional self-harm, and there were “definite indicators” of unintentional
self-harm; and
(b) Oliver himself had submitted a healthcare application form asking to see a
doctor, saying that he was “extremely depressed”, his anxiety was “really
high” and he was “not coping at all, please help”;
These important events were not highlighted on Oliver’s SystmOne medical
record, and so the nurse conducting the assessment 6.12.22 was not aware
of either of these important recent events, and did not take them into account
when assessing Oliver;
2) Oliver was allocated a care coordinator on 6.12.12 following the nurse’s
assessment. An appointment was fixed for Oliver to meet the care coordinator
for the first time on 14.12.22. Due to workload pressures, the care coordinator
was unable to fulfil that appointment before he went on leave from 16-
28.12.22. Shortly before he went on leave, the care coordinator conducted a
“RAG rating” exercise to determine whether he should prioritise seeing Oliver,
and determined that Oliver’s case merited the lowest priority RAG rating
( green ). When conducting that RAG rating exercise, the care coordinator did
not take into account:
(a) The prison officer’s urgent TAG mental health referral of 30.11.22
( above ); and
(b) A further TAG mental health referral made by a prison paramedic which
cited “mild concerns” about both deliberate and unintentional self-harm on
Oliver’s part, the details of which had been entered onto Oliver’s
SystmOne medical record.
In addition, the care coordinator did not raise in the mental health team’s daily
forum.the fact that he was unlikely to have time to see Oliver before he went
on leave.
Had the care coordinator taken into account the referrals at (a)-(b) above, and
raised at the daily forum his difficulty in being able to see Oliver, it may well
have been that Oliver’s case would have merited a more urgent response
from the care coordinator or someone else in his stead.
3
Having heard evidence at the inquest from your Trust’s Clinical Director,
, I was not satisfied that the Trust has fully recognized the
above shortcomings, and taken action to ensure that they are not repeated for
other mental health patients in custody at HMP Hewell.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you, as
the Chief Executive of The Midlands Partnership NHS Foundation Trust, which is
responsible for mental health care within HMP Hewell, 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 6 December 2024. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting
out the timetable for action. Otherwise you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Parties at the inquest:
(a)
, Oliver’s mother;
(b) HM Prison and Probation Service;
(c) Practice Plus Group;
(d) West Mercia Police;
(e) GEOAmey.
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
11 October 2024
David REID
HM Senior Coroner for Worcestershire
4
5
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr David Reid HM Senior Coroner for Worcestershire Worcestershire Coroner's Court, The Civic, Martins Way, Stourport-on-Severn, Worcestershire DY13 8UN Dear Sir, Trust Headquarters St George's Hospital Corporation Street Stafford ST16 3SR www.mpft.nhs.uk 06 December 2024 Regulation 28 Report to Prevent Future Deaths regarding the death of Mr Oliver Davies I am writing to you on behalf of Midlands Partnership University Foundation NHS Trust (MPFT) in response to your Prevention of Future Deaths report dated 11 October 2024, following the inquest touching the death of Mr Oliver Davies. At the outset I would like to express my sincere condolences on behalf of MPFT to Mr Davies’ family and friends. This letter is MPFT’s formal response to your PFD report. 1) Oliver had been at HMP Hewell since 20.10.22. He was a man with longstanding mental health issues, for whom this was a first experience of custody. After a steady deterioration in his mental state, a mental health referral on 17.11.22 led to a belated mental health examination conducted by a registered learning disability nurse on 6.12.22. In the week leading up to the nurse’s assessment: (a) A prison officer had made an urgent TAG mental health referral on 30.11.22, citing concerns that Oliver was experiencing active thoughts of self-harm or suicide, and that he (the officer) had “mild concerns” about intentional self-harm, and there were “definite indicators” of unintentional self-harm; and (b) Oliver himself had submitted a healthcare application form asking to see a doctor, saying that he was “extremely depressed”, his anxiety was “really high”, and he was “not coping at all, please help”; These important events were not highlighted on Oliver’s SystmOne medical record, and so the nurse conducting the assessment 6.12.22 was not aware of either of these important recent events and did not take them into account when assessing Oliver. Since the time of Mr Davies’ death, MPFT has implemented a process for managing referrals and patient- related communications at HMP Hewell, centred around the EDiC (Early Days in Custody) model. MPFT staff working within the prison, have been thoroughly briefed on the EDiC model and are provided with a good practice guide, ensuring consistent and efficient handling of referrals and patient communications across services. This process has been circulated to staff by email, discussed in team business meetings and included in staff inductions. There is also now, a clear process for the management of TAG referrals and Healthcare applications ensuring that they are added to and visible in SystmOne. The importance of staff familiarising themselves with recent clinical activity from the electronic patient record has been highlighted to all Inclusion staff as part of the key messages that arise from our monthly Health in Justice Serious Incident Meeting. In addition, this learning was shared with all our Prison services at our monthly Health in Justice clinical governance meeting, and a reminder given to all team managers of the importance in reminding staff of this practice in their regular supervision. 2) Oliver was allocated a care coordinator on 6.12.12 following the nurse’s assessment. An appointment was fixed for Oliver to meet the care coordinator for the first time on 14.12.22. Due to workload pressures, the care coordinator was unable to fulfil that appointment before he went on leave from 16- 28.12.22. Shortly before he went on leave, the care coordinator conducted a “RAG rating” exercise to determine whether he should prioritise seeing Oliver, and determined that Oliver’s case merited the lowest priority RAG rating (green). When conducting that RAG rating exercise, the care coordinator did not take into account: (a) The prison officer’s urgent TAG mental health referral of 30.11.22 (above); and (b) A further TAG mental health referral made by a prison paramedic which cited “mild concerns” about both deliberate and unintentional self-harm on Oliver’s part, the details of which had been entered onto Oliver’s SystmOne medical record. In addition, the care coordinator did not raise in the mental health team’s daily forum the fact that he was unlikely to have time to see Oliver before he went on leave. Had the care coordinator taken into account the referrals at (a)-(b) above, and raised at the daily forum his difficulty in being able to see Oliver, it may well have been that Oliver’s case would have merited a more urgent response from the care coordinator or someone else in his stead As per the response above, staff have been reminded in a variety of forums as to the importance of familiarising themselves with recent clinical activity in the patient’s SystmOne notes prior to any assessment or clinical intervention. Following Mr Davies death, all MPFT colleagues at HMP Hewell have participated in specific clinical supervision focused on the importance of listening to and responding to prisoner concerns. To further support this, the team holds daily team meetings, monthly business meetings, weekly healthcare huddles, and weekly Safety Intervention Meetings (SIM) meetings; all of which have recorded minutes where prisoners' concerns are addressed. Information from the SIM meetings is disseminated to care coordinators via email, ensuring that tasks arising from these discussions can be actioned promptly. All patient concerns are documented on SystmOne by the person who is notified of the concern so that anyone looking at the SystmOne record can see that a concern has been raised. One focus of clinical supervision is to manage patient concerns by mitigating risk and ensuring any care and treatment is planned in accordance with this. There is now also a process embedded within the service to ensure continuity of care during planned and unplanned staff absence. This is set out in the MPFT guidance called “Reallocation when staff are leaving and when absent for 2 weeks or more”. Patients of concern are also discussed within our multidisciplinary forums, both internally within our service, and at joint daily huddles that are now in place led by Practice Plus Group. A standing agenda item of “Provision of Care to Patients in the Absence of Care Coordinator” was added to the Daily Meeting standing agenda. This ensures continuous care for all patients, regardless of staff availability. When a patient concern is raised during these meetings and the assigned care coordinator is absent, the issue is thoroughly discussed among the present team members. A specific worker is then designated to address the concern and assume temporary responsibility for the patient's care. This handover of responsibility is formally documented in the meeting minutes and the patient’s SystmOne record along with rationale. New staff members are introduced to this process during their induction, with details available in the induction folder, and all team members are required to attend these daily meetings. We wish to assure you and Mr Davies’ family that the actions described above are being taken forward with considerate attention. Yours sincerely, Chief Executive Midlands Partnership University NHS Foundation Trust
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