Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0702, written 20 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 | 20 Dec 2024 |
|---|---|
| Reference | 2024-0702 |
| Deceased | Haydar Jefferies |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| Category | State Custody related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 7 |
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: 1. 2. and Probation. , HMP Coldingley , Minister of State for Prisons, Parole 3. 4. 1 CORONER , CEO NHS England , CEO Parole Board I am Caroline Topping Assistant Coroner, for the coroner area of Surrey. 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. INVESTIGATION and INQUEST 3 An inquest into the death of Mr Haydar Jefferies was opened on the 4th April 2023 and resumed with a jury on the 11th November 2024. The inquest was concluded on the 29th November 2024. The jury concluded that Mr Jefferies died on the 5th March 2023 at Frimley Park Hospital, Frimley and the medical cause of his death was: 1a. Hypoxic Brain Injury and Bilateral Pneumonia 1b. Suspension They concluded with a narrative conclusion and found that: MATERIAL CAUSES Haydar died as a result of tying a ligature around his neck. It is not possible to determine his intention. The following are facts that, on the balance of probabilities, have been found to have happened and have made a material contribution to Haydar Jefferies’ death: Between the 18th February 2023 and the 1st of March 2023, Haydar was suffering from psychosis as referenced by the expert psychiatrist. The fact that Haydar was an IPP prisoner and that his parole hearing was delayed more than minimally contributed to the development of this psychosis, due to the psychological stress. In February 2023, during Haydar’s detainment at HMP Coldingley, there was a serious failure by the custodial staff to record risk relevant information in regard to his presentation. Specifically, concerns raised by his family through numerous telephone calls and concerning comments made by Haydar to custodial staff. There was an additional failure to 1 ensure that risk relevant information was shared with prison officers and clinical staff. Between the 18th and 27th February 2023, there was a serious failure to refer Haydar to the Mental Health team. This was despite evidence showing acknowledgement and intent to make a mental health referral on more than one occasion. By 17.30 on the 28th of February 2023, Haydar was floridly psychotic as evidenced by the expert psychiatrist. The proper response would have been to ensure his immediate safety by putting him on constant supervision and taken him to an external place of safety due to Coldingley’s unsuitable provision of safer cells. That none of this was done represents a serious failure by HMP Coldingley custodial staff. There was a failure to undertake a substantive mental health assessment on the 28th February 2023 following the morning referral from custodial staff and the subsequent CSU review. A mental health review was booked in for the following day which was inadequate. POSSIBLE CAUSATIVE MATTERS The following are matters which we have found possibly occurred and more than merely speculatively made a material contribution towards Haydar’s death but we have not found on the balance of probabilities: Such records as were made were across multiple systems with different levels of access, no set expectation of cross referencing and reliant on individual initiative and curiosity to be found. The clinical staff at HMP Coldingley were lacking this initiative and curiosity and thereby missed a pattern of behaviour that they could have identified and used to drive better-informed clinical decisions at point such as the brief CSU rounds and reviews. When the allegation that led to Haydar’s recall was no longer being pursued, there was an opportunity for the Secretary of State to consider an executive release, which was not taken. The IPP parole decision could have been made on “on papers” without the need for a meeting, and this too was declined. The training for custodial staff at HMP Coldingley is inconsistent and inadequate with regard to mental health presentation. The ACCT document and process is unsuitable for a mental health crisis of this kind. NEGLECT The death was contributed to by Neglect. This is in relation to a failure to share risk relevant information with clinical staff and procure mental health intervention for Haydar between the 18th and the 27th February 2023 and a failure to procure medical attention for Haydar after he suffered acute mental health deterioration on the evening of the 28th February 2023. SYSTEM FAILURE The death was caused or more than minimally contributed to by the failure on the part of the Ministry of Justice to ensure there was a system in place for the recording of the family concerns raised in telephone calls to the prison. ADMITTED FAILURES It is admitted that HMP Coldingley ought to have automatically conducted five observations per hour because an ACCT was opened for Mr Jefferies whilst he was on the CSU. It is accepted that only two observations were conducted per hour. 2 4 CIRCUMSTANCES OF THE DEATH Haydar Jefferies was sentenced to imprisonment for public protection (“IPP”) in 2006. He was released in 2013. Haydar then integrated into the community, married and was working as a publican. Following the death of his spouse and his father in 2021 Haydar attempted suicide. In January 2022 allegations were made against him and he was recalled to prison under the terms of the IPP. By April 2022 the allegations were not being pursued. An Executive Release order request was made and declined. ln order to be released from prison Haydar had to attend a parole board hearing. The parole board decided that a hearing in person was required. In May 2022 Haydar disclosed he had made a ligature. A parole board hearing was fixed on the 13th October 2022.The parole board hearing was vacated owing to the unavailability of the chair person. The next parole hearing was listed for the 2nd March 2023. The extended period of detention was detrimental to Haydar's health and he stated to clinical staff he felt hopeless and helpless after his cancelled parole hearing. On the 28th December 2022 Haydar was transferred to HMP Coldingley from HPM Bullingdon. Haydar travelled with prisoners who were aware Haydar had come from the vulnerable prisoners wing and made inaccurate assumptions about reasons for being on the wing. On arrival at HMP Coldingley Haydar’s mental health was reviewed and appeared stable. On 10th February 2023 the Government rejected IPP resentencing. On the 12th February 2023 Haydar asked to be segregated for his own safety in the care and separation unit (CSU). This move was supported by a call from Haydar's mother concerned about his safety. On the 14th February Haydar reported low mood and was unwilling to restart previously prescribed medication for depression. The Independent Monitoring Board (lMB) visited Haydar on February 15th 2023 following the Government rejection of the proposed IPP resentencing. Haydar reported that he had lost hope'. From the 18th February 2023 Haydar developed severe depression with psychosis. Haydar's family made several calls to the prison from 18th February 2023 onwards raising concerns about his safety and deteriorating mental health. These calls were not recorded in any prison records. Haydar made various statements to individual prison staff from 18th February 2023 onwards, which were symptomatic of deteriorating mental health and development of psychosis, including many which were not recorded in any prison records. A number of statements about Haydar's presentation were recorded across a disparate landscape of on and offline recording systems. On the 19th February custodial staff acknowledged the need to refer Haydar to mental health. This referral was never made despite being recorded as having been completed in prison records. On the 26th February 2023 custodial staff identified the need to request a mental health review following Haydar's delusional allegations towards staff. Haydar then experienced auditory and visual hallucinations and reported them to his family and custodial staff. This further evidence of psychosis was not recorded. At this 3 time, Haydar was also not taking part in the CSU regime, remaining in his cell at all times. Prior to the 28th February 2023 neither the information in the family calls nor the concerning statements made to individual prison officers were shared with clinical staff or other prison staff and no referrals were made to the mental health team in relation to Haydar. On the morning of the 28th February 2023, Haydar told custodial staff he had made peace and was ready for staff to kill him. An email referral, followed up by a phone call, was made to the mental health team for Haydar to be seen as soon as possible on the morning of the 28th February 2023. No mental health assessment was conducted that day. ln the afternoon of the 28th February 2023 Haydar attended a CSU review. During the review Haydar requested a mental health assessment. As part of the review documentation, the CSU algorithm was completed as 'no psychosis'. Evidence provided by an expert witness determined that in fact Haydar was psychotic from 18th February 2023, and on the morning of the 28th had demonstrated red flag behaviour. The CSU review document was not fully completed. The box relating to mental health concerns was left blank. At around 16.30 on the 28th February 2023 Haydar was observed in his cell, flushing his head down the toilet, naked, on all fours, barking like a dog and he said a female officer had told him to behave like this. At this stage Haydar was floridly psychotic. An ACCT was opened at 17.30. The ACCT was not fully completed with a justification for Haydar to remain in CSU. No Defensible Decision log was completed. No medical advice was sought and no medical treatment obtained for Haydar on the evening of the 28th February 2023. The medical team were still on site at the time the ACCT was opened. Observations were incorrectly set at 2 per hour and only constant observations would have been sufficient to ensure safety. Haydar remained on the CSU. This was not appropriate, outside provision should have been sought. During CSU observation, Haydar was found to be slumped over the toilet in his cell. At 2.40 on the 1st March 2023 Haydar was found in cardiac arrest having self -ligatured in his cell. Paramedics attended within minutes and resuscitated Haydar and transported him to Frimley Park Hospital where he was admitted at 04.45 on 1st March 2023. Haydar had sustained a hypoxic brain injury. Haydar was pronounced dead at 15.11 on the 5th March 2023 at Frimley Park Hospital. His death was caused by hypoxic brain injury and pneumonia. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Evidence was provided by HMP Coldingley and Central North West London NHS Foundation Trust (“CNWL”) in relation to the matters found 4 by the jury. The organisations have taken the matters that led to Haydar’s death seriously. CNWL are putting in place protocols and training to ensure that staff are better informed before assessing and reviewing prisoners on CSU. HMP Coldingley are in the process of amending their safer custody policy but to date this has not been produced. I therefore remain concerned as follows: In relation to HMP Coldingley: 1. There is no system in place to ensure that information provided in telephone calls in relation to a prisoner’s welfare is recorded. 2. Matters of concern in relation to prisoners are recorded across a number of different records and there is a risk that the information is missed and not disseminated in daily briefing sheets. 3. There is no composite document for clinicians to review to see all relevant information recorded by custodial staff about a CSU prisoner for the proceeding 24 hour period. 4. There is no system in place to check that referrals to the mental health teams requested by senior members of the prison staff have in fact been made. 5. Custody staff are not trained in mental health presentations and are unable to recognise red flag indicators of declining mental health. In relation to HMP Coldingley and NHS England: 6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result: a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions. b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning. 7. The ACCT process is not designed nor effective to protect prisoners in acute mental health crisis who do not appear to be suicidal. In relation to the Parole Board: 8. Imprisonment under an IPP is a recognised suicide risk. The delay in dealing with the IPP parole hearing exacerbated the risk. There is currently no process in place to expedite face to face parole hearings for IPP prisoners when allegations leading to their recall have been withdrawn and no criminal action is being considered. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR 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 14th February 2025 . 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 5 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 Persons: Mr Jefferies Family Central North West London NHS Foundation Trust (“CNWL”) I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 Caroline Topping 20th December 2024 6
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Secretary of State for Health and Social Care 2. The Secretary of State for the Department for Science, Innovation and Technology 3. The Medical and Healthcare Regulatory Authority 4. The Financial Conduct Authority 5. The Chief Coroner 1 CORONER I am Amanda Bewley, Assistant Coroner, for the coroner area of Nottingham and Nottinghamshire 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 On 7 March 2024, I commenced an investigation into the death of Susan Marie Karakoc. The investigation concluded at the end of the inquest on 28 November 2024. The conclusion of the inquest was a narrative conclusion: Susan Marie Karakoc sought to treat her symptoms of fibromyalgia with and which she obtained from websites selling prescription medication off- label. Susan had levels of at a potentially toxic level. Those medications taken together acted synergistically to depress Susan’s cardiorespiratory system which led to her suffering hypoxic brain injury which in turn caused her to suffer multiple organ failure which led to her death. associated with fatalities and 4 CIRCUMSTANCES OF THE DEATH On 1 December 2023, Ms Karakoc collapsed at her home address. She was found by a family member and transported to hospital by ambulance. Investigations at hospital found Ms Karakoc had suffered a hypoxic brain injury which was not survivable. Ms Karakoc died on 2 December 2023. Following Ms Karakoc’s death, toxicological examination revealed that the catalyst for the toxicity. chain of events leading to Ms Karakoc’s death was Ms Karakoc was not prescribed either of these medications by her General Practitioner and the General Practitioner was unaware of Ms Karakoc taking those medications. and Ms Karakoc’s family provided evidence which proved that Ms Karakoc obtained these medications from online sources via websites set up to sell prescription medication off- in a period label. Ms Karakoc made over 100 purchases of of a little over a year. The ready availability of medications such as these to purchase from websites circumvents the patient safety measures in place and places vulnerable persons at risk of death. This represents a real and ongoing risk of future deaths occurring. and 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. There is evidence of search engines readily returning websites which sell prescription medications, including those that sell highly addictive sleeping tablets and painkillers which can and do cause fatalities. I am concerned how readily search engines return websites such as these; 2. I am concerned that the current system for monitoring the legitimacy of supply chains for medications available in England and Wales via prescription is not preventing the ready supply of such medications online; 3. There is evidence that banks form a legitimate part of the supply chain, and that this is crucial to the functioning of these criminal enterprises. I am concerned that the current system for detecting such criminal enterprises and alerting the relevant authorities is not effective. I am not reassured that necessary actions to address the serious issue identified are in place. ACTION SHOULD BE TAKEN 6 In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action in relation to at least one of the concerns identified herein. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 10 February 2025. 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 Interested Persons: - Susan Karakoc’s family I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I will send a copy of my report to the following: 1. The Secretary of State for Health and Social Care 2. The Secretary of State for the Department for Science, Innovation and Technology 3. The Medical and Healthcare Regulatory Authority 4. The Financial Conduct Authority I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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. Amanda Bewley HM Assistant Coroner Nottingham and Nottinghamshire Coroners Service 17/12/2024
7 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.
Assistant Coroner Topping HM Coroner for Surrey HM Coroner's Court Station Approach Woking Surrey GU22 7AP 18 December 2024 Dear Ms Topping Litigation Group 102 Petty France Westminster London SW1H 9GL T 020 7210 3000 www.gov.uk/gld Your ref: Haydar Jefferies (Deceased) Our ref: Haydar Jefferies (Deceased) ( ) - Death in custody on 5 March 2023 - HMP Coldingley Please find enclosed a copy of the Safety Strategy Policy dated December 2024, for HMP Coldingley. The updated policy encompasses the key learning outcomes following the sad death of Haydar Jefferies. The two further queries and responses are dealt with as follows: 1. The fact that information? says that the new referral form does not always include enough As outlined on page 12 of the December 2024 Safety Strategy, the prison is rolling out mental health training for Custodial Managers and CSU Staff to assist with populating the referral form with all relevant information in respect of risk and to support custodial prison staff in identifying mental health concerns more readily. Custodial Managers can check that mental health training has been completed by accessing officer training records through the online management system. Any new staff that have successfully passed a board to work in the CSU, must have also completed the online training prior to being invited for interview. The prison expect all existing staff in these positions to have completed the training by the end of January 2025 and that new recruits into these positions will be required to complete the training before taking up post. The prison is committed to ensuring mental health concerns are referred to the mental health team as early as possible. This may mean on occasion that the information is slightly more limited than the mental health team would like in order to gain a comprehensive understanding of the issues, but this at least puts the mental health team in a position to make further enquiries and bring their expertise to the assessment urgently. It is important to acknowledge that the referral form is designed by the Mental Health team. The Prison is willing to publish an amended version if the Mental Health team identify that they require the inclusion of specific information. - Head of Division - Deputy Director, Team Leader MOJ & Inquests 1 2. The jury finding that records are across multiple systems with different levels of access with no set expectation for cross referencing. The prison is committed to ensuring information is captured and disseminated efficiently and effectively. Certain information needs to be recorded in specific areas/working logs to ensure that information is noted by the correct staff members who then filter and prioritise the information so that it is actioned meaningfully. Necessarily there are systems to filter and distil the information to key facts and issues, otherwise, there is a real risk of information overload. For example, what is useful and important for a wing officer to read in the Observation Book may be excessive detail for the senior managers to read in the daily briefing sheet. It is also important to note the necessity of having a separate healthcare system to ensure patient confidentiality. To drive improvement in terms of better cross referencing of information, there is now an expectation that any contact from a concerned relative or friend of a prisoner is recorded as a case note on P-Nomis and the Safety Team will be notified of the interaction. The entry is then added to the Daily Briefing Sheet and discussed at the next Safety Intervention Meeting. Where applicable, there is also an expectation that these entries are captured in other areas such as the Wing Observation Book, ACCT records and/or Mercury Intelligence Reports. These requirements have been implemented in the December 2024 Safety Strategy Policy as annexed to this letter. The importance of logging calls has been communicated to staff by weekly video links, a notice to staff and discussed at staff briefings. Any failure to comply with this requirement will be challenged and may result in disciplinary or performance management action being taken. We do hope this clarifies the position of the prison. If the prison can be of any further assistance, please do not hesitate to get in touch. Yours sincerely For the Treasury Solicitor D E - 2 -
OFFICIAL
Director General Operations
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London
SW1H 9AJ
14 February 2025
Caroline Topping
Assistant Coroner
HM Coroner’s Court
Station Approach
Woking
Surrey
GU22 7AP
Dear Ms Topping,
Thank you for your Regulation 28 report of 20 December 2024, addressed to the Minister of
State for Prisons, Probation and Reducing Reoffending, and to the Governor of HMP
Coldingley. 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 the family of Mr Jefferies, 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 recording and
sharing of key risk information and around mental health awareness. I will address each of
your concerns that relate to HMP Coldingley in turn.
Firstly, I wish to clarify that the prison sent an updated copy of the safer custody policy
document, named the Safety Strategy, by the agreed deadline of 18 December 2024. As
you have been provided with a copy, I will not detail the changes made to the policy but can
assure you that the strategy does set out relevant action which addresses the concerns you
raised during the inquest.
You have raised concerns that there is no system in place to record welfare concerns about
prisoners when they are reported into the prison, and that when matters of concern are
recorded this is not always documented in the same place. I have received assurance from
the Governing Governor of HMP Coldingley that the prison has developed and embedded a
new process to ensure that important information relating to the welfare of prisoners is
recorded and shared appropriately. Any contact from a concerned relative or friend of a
prisoner must be logged as a case note on P-NOMIS, the National Offender Management
Information System used by the prison service, and the Safety team must be informed. That
information is then added to the daily briefing sheet and discussed at the next Safety
Intervention Meeting (SIM), a weekly multi-disciplinary meeting where the most at risk
OFFICIAL
OFFICIAL
prisoners are discussed. This requirement has been added to the updated local Safety
Strategy. You may wish to note that in response to Mr Jefferies’ death, the prison now
discuss prisoners serving an Imprisonment for Public Protection (IPP) sentence at the SIM.
I understand that your concern that relevant risk information was not consolidated in one
place and disseminated in daily briefing sheets was addressed by the prison in a letter sent
to you on 18 December 2024. I do not wish to duplicate the response but can assure you
that the prison remains committed to ensuring that relevant information is identified and
shared appropriately.
You have raised a concern that there is no composite document for clinicians to review
which contains relevant information recorded by prison staff about prisoners in the Care and
Separation Unit (CSU). There is now a morning briefing for CSU staff, attended by
healthcare and the mental health team which takes place prior to healthcare’s rounds, when
all CSU prisoners are reviewed. Documented concerns are shared each morning at the
briefing. Collaborative working and communication between prison staff, healthcare and
mental health colleagues has improved through multi-disciplinary meetings which support
the sharing of relevant risk information and actions to help prisoners identified as at risk of
suicide and self-harm.
Your final concerns relate to prison staff’s awareness of mental health, including making
referrals to the mental health team and recognising when a prisoner’s mental health is
declining. Following Mr Jefferies’ death, the mental heath referral process was reviewed
and the referral form was redesigned to simplify the process. The form is now available
electronically so that staff can easily access it when needed, and when a referral has been
requested by a senior member of staff they must document that this request has been made
and record the name of the staff member tasked with completing the referral. Through
improved multi-disciplinary working, there are more opportunities to check that referrals to
the mental health team have been completed and received by the mental health team.
The prison is piloting an online e-learning course called ‘introduction to Mental Health’ for all
staff working in the CSU to support staff in identifying indicators of declining mental health
and to upskill staff to complete the mental health referral forms with relevant risk
information. All new staff applying to work in the CSU must complete this course.
The prison’s Safety Strategy also sets out that all managers, particularly night Orderly
Officers and those in charge of the prison when healthcare colleagues are not available
must consider using out of hours options when concerns for a prisoner’s mental health have
been raised. This includes phoning 111 – the NHS emergency non-life threatening phone
number which now offers mental health crisis support.
In addition to the action taken locally at HMP Coldingley, I can confirm that all new prison
officers complete a training module called ‘Introduction to Mental Health Awareness’ as part
of their initial prison officer training.
Thank you again for bringing your concerns to my attention. I trust that this response
provides assurance that action has been taken to address your concerns.
Yours sincerely
OFFICIAL
OFFICIAL
Director General of Operations
OFFICIAL
Ms. Caroline Topping
HM Assistant Coroner
HM Coroner’s Court Surrey,
Station Approach,
Woking
GU22 7AP
Dear Ms Topping,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
12 March 2025
Re: Regulation 28 Report to Prevent Future Deaths – Haydar Jefferies who died
on 5 March 2023 at Frimley Park Hospital whilst under detention at HMP
Coldingley.
Thank you for your Report to Prevent Future Deaths (hereafter ‘Report’) dated
20 December 2024 concerning the death of Haydar Jefferies on 5 March 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Haydar’s family and loved ones. NHS England is
keen to assure the family, and the Coroner, that concerns raised about Haydar’s care
have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused Haydar’s family or friends. I realise that
responses to Coroners’ Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones, and I appreciate
this will have been an incredibly difficult time for them.
Your Report raises the concern that, outside of weekday office hours, there is no
mental health clinical provision and that overnight staffing levels at HMP Coldingley
make it difficult for prisoners in mental health crisis to be taken to hospital. As a result,
you raised that:
a) custodial staff take decisions about how to keep prisoners safe overnight without
the necessary clinical knowledge to assess the risks presented by their mental
health conditions; and
b) it is not possible for medication to be obtained to alleviate any acute mental health
symptoms between 6.30pm and 7.00am the following morning.
I note your concern around overnight staffing levels and the lack of clinical presence
overnight, outside of weekday hours. For clarity, I can explain that not all prisons in
England provide 24-hour healthcare so there is no overnight clinical presence. HMP
Coldingley is a Category C establishment, which means it is considered as someone’s
‘usual residence’, or home. There is therefore no provision for overnight healthcare.
In the event of there being serious concerns about an individual’s health, it is expected
that a 999 call is made to request an ambulance in the same way an ambulance would
be called for a person in their own home. This falls under what is described as ‘urgent
referrals’.
I would also like to inform you that since Haydar’s tragic death, the healthcare at HMP
Coldingley, including mental health services, has been re-commissioned.
As of 1 April 2023, the new provider is contracted to provide the following:
• Primary care services: Delivered seven days per week between the hours of
07.00 and 19.00 Monday to Friday, and between 08.00 and 17.30 on weekends
and public holidays.
• Mental health services: These services are delivered seven days a week at a
minimum, Monday to Friday 08.00 until 20.00 and ‘on call’ from 10.00 until
16.00 on weekends and public holidays. There is also on-site attendance
available seven days a week.
Within the new contract, if there is a requirement for any emergency treatment, such
as medication to alleviate any mental health symptoms, for example, the following
applies:
• Emergency referrals: Must be made within two hours when primary care
services are on-site
• Urgent referrals: Must be made within twenty-four hours, with protocols in
place with out of hours (OOH) service providers to manage any urgent cases
that arise during the OOH period. These are provided through Integrated Care
Board (ICB) commissioned services or specialised services. This also includes
999 calls where there are serious concerns as mentioned above.
Contract Management Processes are in place to ensure that emergency and urgent
referrals are reviewed and monitored regularly. This is a quarterly process which is
audited and recorded. With regards to any urgent issues identified, these are reported
via Datix (a digital system for reporting incidents and risks used to support risk
mitigation and regulatory compliance) and acted upon immediately.
The Service Specification for primary (medical and nursing) and dental care provision
in prisons, published in 2020, and the Service Specification for integrated mental
health service for prisons in England, published in 2018, both support the regional
commissioning and contract management process for primary care and mental health
service provision. These service specifications detail core service delivery and the
standards that providers are expected to prioritise, including expected outcomes.
A review of the NHS England health and justice service specifications is being
undertaken by NHS England through 2025 to 2026, and any learning from this case
will be used to ensure that the primary care specification continues to support
commissioners to be able to tailor services to meet the needs of their prison
population.
In addition to this, NHS England and His Majesty’s Prison and Probation Service
(HMPPS) are working collaboratively to produce the Joint Care and Separation Unit
Standards Framework. This will be rolled out later in 2025, along with a range of
resources to support implementation, at establishment level, once the Segregation
Policy Framework is published. This supports a multi-disciplinary approach to
healthcare, including mental health, for people in segregation. There will be a planned
implementation phase to support healthcare, and governors will adopt the standards
over an agreed period, which will be determined by HMPPS.
I note your Report also directs a concern to both NHS England and HMP Coldingley,
that the Assessment, Care in Custody and Teamwork (ACCT) process is not designed,
nor effective, to protect prisoners in acute mental health crisis who do not appear to
be suicidal.
Ownership of the ACCT process and policy lies with HMPPS. NHS England are
therefore not able to comment on this point and would recommend that this is directed
to HMPPS for a full response.
The findings, information and any learning from this case will be tabled at a future NHS
England Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is the
senior leadership forum, which holds responsibility for the oversight of delivery and
continuous improvement in Health and Justice commissioned services, through both
national and regional teams. All health and justice related Reports to Prevent Future
Deaths are shared and discussed at the HJDOG, and assurance is sought from
regions where learning and action is identified.
NHS England’s national health and justice team has also engaged with colleagues
from the South East region on the concerns raised in your Report. For improvements
to be made, a notice will be issued to healthcare staff that they should record a case
note when they ask prisoners if they are having thoughts of self-harm, and they will be
advised that negative responses should also be recorded. Good order and discipline
reviews will now include questions around prisoners’ thoughts on self-harm and
responses will be recorded, and mental health teams will log all referrals on
SystmOne. A new template form for mental health referrals is also being designed,
which will include prompts to include key information to aid triage and details on what
to do with the referral. HMP Coldingley’s Governor will ensure that the new template
is circulated to all operational staff.
I would also like to provide assurance about the national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors and other
clinical and quality colleagues from across the regions. This ensures that key learning
and insight around events, such as the sad death of Haydar, are shared across the
NHS at both a national and regional level. This helps NHS England pay close attention
to any emerging trends that may require further review and action.
I would like to thank you for bringing these important issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely
National Medical Director
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 20 February 2024 Our ref: HM Coroner Amanda Bewley The Council House Old Market Square Nottingham NG1 2DT By email: Dear Ms Bewley, Thank you for the Regulation 28 report of 16 December 2024, sent to the Secretary of State for Health and Social Care, regarding the death of Ms Susan Marie Karakoc. I am replying as the Minister with responsibility for medicine regulation and prescribing. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Karakoc’s death. I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. You raised the following concerns: • • • there is evidence of search engines readily returning websites which sell prescription medications, including those that sell highly addictive sleeping tablets and painkillers which can and do cause fatalities. I am concerned how readily search engines return websites such as these; the current system for monitoring the legitimacy of supply chains for medications available in England and Wales via prescription is not preventing the ready supply of such medications online; there is evidence that banks form a legitimate part of the supply chain, and that this is crucial to the functioning of these criminal enterprises. I am concerned that the current system for detecting such criminal enterprises and alerting the relevant authorities is not effective. Having reviewed these concerns, it is my view that the other departments and agencies with which you have shared the report are best placed to respond directly to the issues you have raised, which are relevant to their respective areas. However, I would like to offer the following information from a Departmental perspective, regarding the safe use of online pharmacies. When used appropriately, online prescribing provides a valuable route for patient access which takes pressure off GP practices. Prescribers, whether working for the NHS or privately, in-person or remotely, are accountable for their prescribing decisions. They are expected to take account of appropriate national guidance. Prescribers should work with their patient and decide on the best course of treatment, with the provision of the most clinically appropriate care for the patient always being the primary consideration. In addition to the duty of the prescriber, patients themselves must be honest when providing information to an online prescriber so that they receive advice and medicines which are appropriate for them and so that risks can be managed. Prescribers need full information to be able to prescribe safely. The General Pharmaceutical Council has published guidance introducing new and strengthened safeguards and checks that online pharmacies must put in place when supplying high-risk medicines. This guidance will also strengthen areas including consultation and communication with the person seeking a medicine/treatment. The updated guidance can be found here: Online pharmacies to strengthen safeguards to prevent unsafe supply of medicines | General Pharmaceutical Council The General Pharmaceutical Council (GPhC) and other professional regulators, Care Quality Commission (CQC) and the Medicines and Healthcare products Regulatory Agency (MHRA) have the powers to investigate and take action against prescribers, products and suppliers who do not comply with legislation and national guidance. In preparing this response, my officials have made enquiries with the Medicines and Healthcare products Regulatory Agency (MHRA) to ensure we adequately address your concerns. MHRA has shared their response with us and I am pleased to note that the website accessed by the deceased was subject to a MHRA investigation, prior to the issuing of the Regulation 28 Report, and a domain suspension request was issued in March 2024 resulting in the website being taken down. The MHRA’s response also includes a list of future criminal countermeasures, which is set to include: • Enhanced collaboration with search engine and UK internet service providers (ISPs) aimed at blocking harmful content through targeted ISP-filtering; • Collaboration the Office of Communications (Ofcom) to explore fresh preventative opportunities presented by the Online Safety Act, which will create new rules for social media companies and search engine providers; • Boosted collaboration with UK Border Force, allowing the MHRA to grow its operational footprint at the border and increase the seizure rates of illegally trafficked medicines; • The use of cutting-edge technology to identify, track and seize the proceeds of crime, including cryptocurrency; • Rollout of a web-based online pharmacy checker that will allow users to search if a • website or social media listing has been deemed fraudulent by the MHRA. Implementation of a web-based reporting scheme allowing users to report suspicious websites, online marketplaces and social media listings to the MHRA; • Continued commitment internet infrastructure community, including private sector and international law enforcement partners. to enhancing collegiate working across The MHRA also seeks to identify individuals involved in unlawful activity and where appropriate, prosecute those who put public health at risk. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
Secretary of State for Science, Innovation and Technology 100 Parliament Street London SW1A 2BQ www.gov.uk/dsit 4 March 2025 Dear Ms Bewley, Thank you for the opportunity to respond to this Report to Prevent Future Deaths, regarding the death of Susan Marie Karakoc. I was incredibly saddened to read about the circumstances surrounding Susan’s tragic death and would like to extend my deepest condolences to her family and friends for their loss. I would like to thank you for bringing this to my attention. Some of the key issues of concern that you raise in your report are within the remit of The Medicines and Healthcare Products Regulatory Agency, and I understand that they have provided a separate response. As the Secretary of State for Science, Innovation and Technology I am responsible for the Online Safety Act 2023 (‘the Act’) and will respond to the issues raised in this report as per my department’s remit. My department has been taking steps to tackle criminal activity online through the Act, which received Royal Assent in October 2023. A service is in-scope of the Act if it allows user-generated content (for example, it has been uploaded or shared by a user of a service as opposed to uploaded or published by the site or service owner). The Act gives online platforms duties to tackle illegal content and activity on their services. Within these duties, the Act establishes certain ‘priority offences’. Priority offences reflect the most serious and prevalent illegal content and activity, against which companies must take proactive measures, as well as ensuring their services are not used to facilitate or commit a priority offence. The illegal sale or supply of controlled drugs is a priority offence under the Act. This offence may be committed where a user unlawfully produces, supplies or offers to supply controlled drugs, or where a user supplies items used for administering or preparing controlled drugs. It is also a priority offence for a person to do anything which incites another to commit these drugs offences, and any content present on a service which does so is ‘illegal content’ under the Act. Platforms, and also search services such as Google, will therefore need to put in place systems and processes to ensure users do not encounter this illegal content via their services. They will also need to take steps relating to the design and operation of their service to reduce the risk that services facilitate these offences. The strongest protections in the Act are for children. In-scope services that are likely to be accessed by children will have a duty to take steps to prevent children from encountering legal but nonetheless harmful content that has been designated as ‘primary priority’ content. This includes content that encourages, promotes, or provides instructions for self-harm, eating disorders or suicide. Search services must also minimise the risk of children encountering this content in search results or on the pages they land on when they click on them. We expect the illegal content duties to be fully in effect from Spring 2025, and the child safety duties from Summer 2025. Ofcom is the independent regulator for the Online Safety Act. It will set out the specific steps providers can take to fulfil their duties in codes of practice. Ofcom has published the final drafts of its first codes for the illegal content duties and we anticipate these will take effect next month. Th e codes set out a range of cross-cutting steps that providers can take to tackle illegal drugs-related content and activity on their services. Ofcom is working with the government to implement the Act as quickly and effectively as possible. Yours sincerely, Secretary of State for Science, Innovation and Technology
Ms Amanda Bewley HM Assistant Coroner Nottingham and Nottinghamshire Coroners Service 14 March 2025 Dear Ms Bewley, Re: Prevention of Future Deaths report The Financial Conduct Authority (FCA) response in relation to Susan Karakoc: Prevention of future deaths report, published on 27 December 2024: https://www.judiciary.uk/prevention-of-future-death-reports/susan-karakoc- prevention-of-future-deaths-report/ Under section 5 of the online report, the following concern was raised: “There is evidence that banks form a legitimate part of the supply chain, and that this is crucial to the functioning of these criminal enterprises. I am concerned that the current system for detecting such criminal enterprises and alerting the relevant authorities is not effective”. We received a copy of the report on 26 February 2025, where you requested that the FCA respond to the points raised in the report. The Money Laundering, Terrorist Financing and Transfer of Funds (Information on the Payer) Regulations 2017 require firms to complete checks as part of the supply chain. This includes where they hold evidence of suspicious activity. In Registered as a Limited Company in England and Wales No.1920623. Registered Office: 12 Endeavour Square, London E20 1JN support of this legislation, where FCA regulated firms do identify suspicious activity, our expectations are for those firms to take action. This may include blocking particular transactions. Firms use merchant details to understand where customer payments are being made to, and firms use these to prevent transactions where they identify suspicious activity or fraud. Suspicious activity can be identified by firms through receipt of intelligence, including from law enforcement, through receipt of serious complaints, unusual frequency and values of payments, and other similar sources. Absent of such intelligence, it would be practically difficult for a firm to identify and prevent payments to a particular merchant. We sympathise with the death of Ms Karakoc. We have considered this matter, and based on the published report we do not consider the circumstances of Ms Karakoc’s passing require additional actions for the FCA. We will share this response with HMT, who lead policy in regards to the AML regulations. We constantly keep our rules and guidance under review. I hope this response is helpful in clarifying our approach. Yours sincerely, Director, Retail Banking Supervision, Policy & Competition 2
10 South Colonnade Canary Wharf London E14 4PU United Kingdom gov.uk/mhra Ms Amanda Bewley Assistant Coroner of Nottingham and Nottinghamshire By Email: Reference: 31 March 2025 Dear Ms Bewley, Regulation 28 report relating to the death of Susan Marie Karakoc Thank you for your Regulation 28 report relating to the death of Ms Susan Marie Karakoc which was received on 16 December 2024. I would like to offer my sincere condolences to Ms Karakoc’s family on their tragic loss. Please accept my sincere apologies for the delay in responding which was due to misunderstanding as to whether we should be replying to you directly. We had provided a contribution to the response by the Department of Health and Social Care (DHSC). The Medicines and Healthcare products Regulatory Agency (MHRA), acting on behalf of the Secretary of State for Health, is responsible for the regulation of all medicines and medical devices marketed in the UK by ensuring they are effective and are acceptably safe. This includes applying the legal controls on the retail sale, supply and advertising of medicines which are set out in the Human Medicines Regulations 2012. These regulations apply equally to medicines advertised, sold or supplied via the internet. The sale and supply of unregulated medicinal products is a global problem. Online portals play a significant role in transnational medicines crime and many websites proliferate across the internet. Currently, there is no legal mechanism for UK law enforcement to seize control of illicit domains or compel registrars to suspend them. Gaining regulatory compliance can be a difficult and sometimes impossible process, especially when domains are registered beyond the reach of UK jurisdiction. We can confirm that the website accessed by the deceased was subject to an MHRA investigation prior to the issuing of the Regulation 28 Report and a domain suspension request was issued in March 2024 resulting in the website being taken down. Public safety is the top priority for the MHRA, and its Criminal Enforcement Unit works hard to prevent, detect and investigate illegal activity involving medicines and medical devices. In 2024, the MHRA and its partners seized millions of doses of illegally traded medicines. These products included prescription-only anti-anxiety medicines, opioids and sleeping pills, and falsified and unlicensed lifestyle products used in the treatment of erectile dysfunction, hair loss and weight loss. It also disrupted thousands of links to websites and social media pages selling medical products to the public illegally. We work closely with web-based sales platforms and the internet industry to identify and remove non-compliant medicines and medical devices where possible. Collaboration with one well-known online marketplace allowed the use of technology to identify and block more than a million unregulated medicines and medical devices before they could be advertised to the public. Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, we are constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include: • Enhanced collaboration with search engine and UK internet service providers aimed at blocking harmful content through targeted ISP-filtering. • Collaboration the Office of Communications to explore fresh preventative opportunities presented by the Online Safety Act, which will create new rules for social media companies and search engine providers. • Boosted collaboration with UK Border Force, allowing the MHRA to grow its operational footprint at the border and increase the seizure rates of illegally trafficked medicines. • The use of cutting-edge technology to identify, track and seize the proceeds of crime, including cryptocurrency. • Continued commitment to enhancing collegiate working across internet infrastructure community, including private sector and international law enforcement partners. • Collaboration with UK banking and payment providers to disrupt the payment mechanisms used by websites illegally supplying prescription only medicines. We seek to identify individuals involved in unlawful activity and, where appropriate, prosecute those who put public health at risk. As the illegal sale of medicines can pose a serious risk to public health, our Fake Medicines campaign https://fakemeds.campaign.gov.uk/ aims to encourage people in the UK who choose to buy medication online to take steps to ensure they use safe and legitimate sources. It also encourages people to report suspicious medicinal products and adverse side effects via our Yellow Card scheme https://yellowcard.mhra.gov.uk/. The efforts of the MHRA and its partners have led to more medicines being seized than ever before, significant custodial sentences for offenders, the forfeiture of criminal profits and considerable success in disrupting the illegal trade online. In this response I have commented on the areas of your recommendations which fall within our remit, and we have also contributed to the DHSC response. The DHSC is appropriately placed to advise on prescribing and dispensing matters. Should you have any further questions, please do not hesitate to contact: Yours sincerely, Chief Executive Medicines and Healthcare products Regulatory Agency E:
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