Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0672, written 4 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Dec 2024 |
|---|---|
| Reference | 2024-0672 |
| Deceased | Kayleigh Melhuish |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | State Custody related deaths · Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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M. E. Voisin His Majesty’s Senior Coroner Area of Avon 4" December 2024 REF: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS ~] THIS REPORT IS BEING SENT TO: HMP Eastwood Park Healthcare ~ Practice Plus Group Mental Healthcare — Avon and Wiltshire Mental Health Partnership Trust Ministry of Justice 1 CORONER lam M. E. Voisin HM Senior Coroner for Avon 2 CORONER’S LEGAL POWERS | 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/S/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 19" July 2022 | commenced an investigation into the death of Kayleigh Ann MELHUISH. The investigation concluded at the end of the inquest on 17‘ October 2024. The conclusion of the inquest was Suspension by a ligature contributed to by neglect 4 CIRCUMSTANCES OF THE DEATH Kay arrived at HMP Eastwood Park on 15th June 2022. It was her first time in prison and she had a history of autism, attention deficit and hyperactivity disorder (ADHD), and a personality disorder. She arrived with a suicide and self-harm warning form having been completed as she had tried to ns Staff started a suicide and self-harm monitoring process referred to as an ACCT. Initially Kay was placed on the prison induction wing, subsequently she was moved to Residential Unit 3. During her time at the prison she continued to self-harm, she banged her head, she punched herself, she made scratches and cuts to herself, she made ligatures and was found with them on two occasions. She found it difficult to cope with the noisy environment and prison regime. On 21st June a neurodiversity specialist met her and created a communications support plan for her. This set out the difficulties she had with noise, smells, food, and physical contact, it suggested ways for people to understand and interact with her. On 4th July Kay cut her arms in the morning, a nurse cleaned her wounds and Kay handed to her a ligature that she had made. ie Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL At around 6.30pm Kay could not be found and after a search she was located hiding under a table in the association room. She refused to go back to her cell. She was restrained and carried back to her cell by officers. At 7.26pm 3 officers went into her cell and found her hanging, she was cut down and cardio-pulmonary resuscitation is commenced. Paramedics arrive and she is then taken to Southmead Hospital. Kay died on 7th July 2022. During her numerous ACCT case reviews her care plan with support action was never completed. After the control and restraint constant observations were not considered. There was little understanding by the prison staff of Kay's neurodiversity. 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. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff: a. Neurodiversity, | am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory; b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews; c. Little or no understanding of when constant supervision can be used and how is it used; 2. Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken. 3. To HMP Eastwood: the ligature point in Residential Unit 3 where the privacy screen meets the wall. e@ Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL ACTION SHOULD BE TAKEN tn my opinion action should be taken to prevent future deaths and | believe you 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 28'" January 2025. |, 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 | have sent a copy of my report to the chief coroner and to the following interested persons a Kayleigh’s family b HMP Eastwood Park ¢ Healthcare — Practice Plus Group d Mental Healthcare — Avon and Wiltshire Mental Health Partnership Trust e Ministry of Justice lam 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 Aignature M. E. Voisin HM Senior Coroner for Avon ourt, eston Road, Flax Bourton, BS48 1UL
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.
Ms Maria Voisin
HM Senior Coroner for Avon
Coroner’s Court
Old Weston Road
Flax Bourton
Bristol
BS48 1UL
Avon and Wiltshire
Mental Health Partnership Trust
Bath NHS House
Combe Park
Bath
BA1 3QE
By email only: 27 January 2025
Inquest into the death of Kayleigh Ann MELHUISH
Regulation 28 Report to Prevent Future Deaths
Dear Ms Voisin,
Thank you for your Regulation 28 Report dated 4th December 2024 concerning the tragic
death of Kayleigh Ann Melhuish who died on the 7th July 2022.
I would like to begin by offering my sincere condolences on behalf of the Trust to the family
and friends of Ms Melhuish.
In your report you highlighted your concerns in relation to:
ACCT reviews – Training re: Review/Update of Care Plan & support actions.
The Trust has reviewed our involvement and input into the ACCT process, and revised the
Local Operating Procedure for ACCT attendance (attached). This was discussed and signed
off at the service level Quality and Standards meeting on 22nd January 2025.
To ensure adherence with this procedure, the Quality and Standards meeting will monitor
completion of ACCT training and refreshers through an audit schedule, which will also
include monitoring improvements in standards across record keeping in ACCT and
SystmOne.
Chair
Trust Headquarters
Bath NHS House, Newbridge Hill, Bath BA1 3QE
Chief Executive
A Quality Improvement Plan has been developed to support this and is attached.
I hope this letter and attachments provide assurance that the Trust takes learning very
seriously and that we have taken action to address the concerns you raised.
I would be happy to meet with you and discuss our work to improve patient safety in more
detail, or provide further information and assurance should that be helpful.
Yours sincerely
Executive Director of Nursing & Quality
Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email: 17 July 2025 Maria Voisin Senior Coroner for Avon Old Weston Road Flax Bourton, Bristol, BS48 1UL Dear Ms Voisin, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – KAYLEIGH MELHUISH Thank you for your Regulation 28 report of 4 December 2024 following the inquest into the death of Kayleigh Melhuish at HMP Eastwood Park on 7 July 2022. I am responding on behalf of both HMP Eastwood Park and the Ministry of Justice. I am very sorry for the delay in responding to your report which was the result of an administrative oversight. I know that you will share a copy of this response with Ms Melhuish’s family, and I would firstly 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. Your report raises concerns regarding: the prevalence of neurodiversity within the population and a lack of related training for staff; inadequacies in understanding amongst staff of Assessment, Care in Custody and Teamwork (ACCT) processes, including when to use constant supervision, and the existence of a ligature point in one of the residential units at the prison. As you heard in evidence at the inquest, HM Prison and Probation Service (HMPPS) is undertaking significant work to understand and raise awareness amongst staff of neurodiversity issues and the impact that they can have in the custodial environment. In recognition of the importance of such issues, staff undergoing initial training receive training on diversity and inclusion, personality difficulties and neurodiverse conditions including autism are discussed and consideration is given to how staff can support prisoners with these needs. This training covers issues such as how best to conduct searches of individuals and how to manage disciplinary processes that may impact negatively on those with neurodiverse conditions. For existing staff, the online learning platform to which all staff have access contains training modules relating to neurodiversity including Neurodiversity-Autism/ADHD and Neurodiversity-Learning Disabilities and Challenges. We have recruited Neurodiversity Support Managers (NSMs) across the prison estate to ensure that support for neurodiverse prisoners is consistent across all education, skills and work opportunities as well as the wider prison. One of the main responsibilities of the NSMs is to provide training and support for other prison staff to help them better understand and support those with neurodivergent needs within the prison. The NSMs are also responsible for implementing a whole prison approach to supporting neurodivergent needs with improved processes. This can include ensuring that all information and forms are available and/or designed with suitable adaptations, and that reasonable adjustments are made for prisoners with a disability so that they are not unfairly disadvantaged and can access all parts of prison life. We have also developed a ‘National Neurodiversity Training Toolkit’ that is available for all frontline staff within prison and probation, developed by and with neurodivergent staff, in cooperation with HMPPS and Ministry of Justice staff networks. Eastwood Park has employed a Speech and Language therapist and a Neurodiversity Strategic Lead to work alongside the local NSM. The NSM delivers an introduction on neurodiversity to all new staff during their training period. This session includes highlighting common characteristics of neurodiverse people and best practices when working with them and provides staff with the opportunity to ask any questions they may have to deepen their understanding. Turning to your second concern, I agree that it is essential that ACCT procedures are understood by staff, and in particular that ACCT case co-ordinators are aware of the importance of reviewing actions at case reviews and are confident in knowing the circumstances in which constant supervision would be appropriate. These issues are covered in the case review training that is provided to ACCT case coordinators, and a case review refresher course is also available for staff to attend. A new quality assurance process for ACCT has also been developed and provides an opportunity for managers to offer feedback to case co-ordinators to enhance their performance. At Eastwood Park the standard of ACCT case management is monitored through the quality assurance process. Any concerns identified are raised directly with the case coordinators and support sessions are provided for staff. Where concerns continue, these are escalated to line managers. The prison is also facilitating forums for case coordinators to allow further discussion about the ACCT process and supplementary information is shared with staff through the safety Microsoft Teams channel. In the light of your comments the local procedures in relation to constant supervision at Eastwood Park will be reviewed. The Governor expects to complete this work within a month and any changes will be communicated through staff briefings. Additionally at a national level the Safety Group is currently undertaking work to develop further guidance for prisons on constant supervision, which is planned for completion by the end of March 2026. You identified the existence of a ligature point on Residential Unit 3 at the prison. Whilst we aim to minimise the presence of ligature points, including by ensuring that all new and refurbished accommodation meets ligature resistant standards, we are not able to remove all such points across the estate. At Eastwood Park, four ligature resistant cells, spread across three residential units, have been installed for use for prisoners who have been identified as being at risk of suicide by ligature and are expected to come into use shortly. The prison will continue to support prisoners at risk of suicide by ligature with other measures through the ACCT case management system and the case review team would decide on actions such as whether to remove items that can be used to ligature or constant supervision where appropriate to manage the risk. Thank you again for bringing your concerns to my attention and I trust that this response provides assurance that we are addressing them. Yours sincerely, Director General of Operations
Practice Plus Group Building 1330, Arlington Business Park, Theale, Reading, RG7 4SA practiceplusgroup.com M Voisin HM Senior Coroner for Avon Coroner’s Court Old Weston Road Flax Bourton Bristol BS48 1UL By email only: 10.1.2025 Dear Madam, Regulation 28: Prevention of Future Deaths Report – Kayleigh Ann Melhuish I write in response to your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus Group on 4 December 2024 following the inquest touching upon the death of Kayleigh Ann Melhuish at HMP Eastwood Park. Practice Plus Group would like to express its sincere condolences to Kayleigh’s family and friends. This response addresses the matters of concern in so far as they relate to Practice Plus Group only. Matter of Concern 2: Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken. Response: We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions. Unfortunately, Practice Plus Group’s ability to makes changes to SystmOne is limited and this would require action by TPP who own and operate the software. We have forwarded a copy of the Prevention of Future Deaths Report to TPP for their awareness. However, it is important to note that whilst a tick-box could serve as a prompt, it does not provide a mechanism for reporting or ensuring that meaningful reviews and updates are conducted. To address this matter effectively, we remain committed to maintaining robust oversight through regular audits of ACCT reviews. These audits will ensure that care plans and associated support actions are being reviewed and updated appropriately. Practice Plus Group Health and Rehabilitation Services Ltd. Registered in England No 10498997 Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW Additionally, we will continue to collaborate closely with the prison to ensure all relevant staff complete updated ACCT training. This will reinforce the importance of thorough and consistent care plan reviews as part of the ACCT process. As at today’s date, 78% of all clinical staff have completed ACCT training and we continue to work with the prison to ensure access to regular ACCT training sessions. Practice Plus Group conduct regular audits of the ACCT process, in October and November 2024 Healthcare attended 100% of all ACCT reviews and this is documented on SystmOne. We will continue to monitor this process. It is important to note that at the time of Kayleigh’s incarceration Practice Plus Group was not a provider of healthcare services at HMP Eastwood Park. Of note, following the last inspection by HM Inspectorate of Prisons and the CQC in October 2022, there were very few recommendations for healthcare at the time. Practice Plus Group actioned all recommendations, having only taken over the contract a few days prior, and have a continuous Quality Improvement Plan in place. I hope that the above response provides assurance that Practice Plus Group are committed to providing a high-quality healthcare service at HMP Eastwood Park and trust this response addresses the concerns you had. We would like to end our response by taking the opportunity of inviting you to visit the healthcare team at HMP Eastwood Park should you wish to discuss and review first-hand the enhancements set out in this letter. Yours sincerely, Associate Medical Director, Health in Justice Practice Plus Group E: Page 2 of 2
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