Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, written 24 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Oct 2016 |
|---|---|
| Deceased | Michelle Barnes |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham and Darlington |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
a National Offender Hd Management Service Dra FI ustody and Public ion Group 4) Offender Management Service Dear Mr Tweddle, Inquest into the death of Michelle Barnes Thank you for your Regulation 28 Report of 24 October 2016 following the conclusion of the Inquest into the death of Michelle Barnes at HMPIYO Low Newto }- Your report has been passed to Safer Custody and Public Protection Group in the National Offender Management Service (NOMS), as we are responsible for policy on suicide preventipn and for sharing learning from deaths in prison custody. | am responding on behalf of the Chief Executive of NOMS and the Governor of Low Newton. | note that G4S Medical Services, the ounty Durham and Darlington NHS Foundation Trust and Tees, Esk and Wear Valley: HHS Foundation Trust have responded to you separately in letters dated/10 November, 15 December, and 16 December respectively. | have responded to the points in your report in the order that you raited them. Ml | would like reassure you that in response to the matters raised in yolir report, the Governing Governor has taken action to ensure that both physical and mental : alth staff are invited to attend the daily senior management meetings. Since November 2016, these meetings have been minuted, with attendees recorded. Additonal, the prison’s He pithcare Governance Board is held bi-monthly and attended by representatives from dentistry, |G, mental health, nursing and pharmacy services as well as physical ealthcare. In the wider prison estate, all establishment usually hold a ‘morning operational issues for the day are discussed. Governing Governo appropriate attendees and agenda items forjthese meetings base establishment. eeting’ in which ill determine the dn the needs of their You raised the concern that Ms Barnes’ birthing plan document was Inadequate and incomplete, and that appropriate and timely consideration was not given to alte! I tive plans. at Low Newton have now lay 2016, and updated in ar guidance to staff ona ancy, the parameters of the birth. It also provides giving birth. been replaced by the pregnancy pathway which was Introduced i October to include mental health provision, This pathway provides range of issues, including how to support a prisoner during her, me contact between the mother and her baby and who can be present a clear guidance to staff escorting women to' hospital for the purpo The needs of preg ant women are considered at the weekly, multl-disciplinary pregnancy pathway meetings. | Attendees are Ceri for drawing up and reviewing a care plan for each pregnant Foman, detailing what will happen after the birth and how the mother will be supported emotipnally and practically, particularly if their baby Is removed from their care. The care plan will takp into account Input from a number of professions, ensuring the most appropriate care/plan Is put into place for|mother and baby. A lead co-ordinator, already familiar with the prisonefjis allocated to support the prisoner throughout the pregnancy, providing continuity of carg and ensuring an understanding of their individual circumstances. Boibeen reviewed to anne that contributions from the local authority are ed at the outset when reviewing applications to the Mother and Baby Unit to te\decision making. The care plan further supports pregnant women by access legal advice "Tl they are contesting local authority decisions Systems have ai carefully conside ensure appropria assisting them t regarding care p Nn updated its local policy on suicide and self-harm to ration and place additio! al emphasis on safer custody issues surrounding , taking into account the potential risks associated Additionally, in take into considg pregnant prisonérs} before and post-deli with their baby Ge In response to yf | can confirm NG and is confident ur, concern that birthing atrangements in other establishments are appropriate, 5 conducted a review pf birthing plan arrangements across the female estate hat that these are being|Implemented appropriately. You have expressed concerns regarding |the way in which the extremely upsetting news that Ms Barnes would ni ic able to keep her bal ese given to her, and the subsequent decision not to open an Assessment, Care in Custod ind Teamwork (ACCT) plan after Ms Barnes was given this news ‘ou also queried whetherjother forms of support, short of opening an ACCT, are available to brigoners in similar circurpstances. ch situations, and apprapriate action has been taken to ensure that this is ‘ ujdance was issued to Low Newton staff In December 2016 about the Hrocess for delivering difficult news to prisoners with children or babies. Where the mother is pré this to the pregram prisoner and beg delivery of the Custody training mothers of babi¢ placed to deliver the ni WS, is Involved. The decision on the timing and pssage will initially be made by the Duty Governor. Annual Refresher Safer re reminded in November 2016 of the importance of ner Is at risk of suicide or self-harm, and the document when a pris d clearly, and making sure there is a multi-disciplinary ording this accurately ai T reviews. importance of re approach to AC There are a nu distress, other t! scheme, where} ber of support mechanisms available at Low Newton for prisoners who are in see the ACCT process. These include the use of the personal officer risoners are cree to positively engage with their designated personal officer to disclose issues and for added support. The chaplaincy tea care and support to prisoners, when requi d. There are trained LI establishment 24 hours a day, alongside the dedicated Samaritans prisoners can request access to at any time. All prisoners are informed of these services on their arrival at the prison, and information on the support avallabl ; igfurther promoted by the workers on the Prisoner Information Desk'on the First Night Centre And in induction sessions delivered by Listeners themselves. There are notices promoting al aritans and Listeners around the establishment displayed on notice boards and at every telephone point on wings. also provides pastoral steners avallable at the elephone line which You express concern that safer custody practices do not consider p soners In a holistic manner. As you are aware, prisoners considered at risk of suicide and self-harm are managed through the ACCT process. The review of the ACCT process undertaken in #015, found that the policy and system are sound, but that work is needed on Improving complitnce with policy and the quality of delivery of care. It is recognised that when used effectivel} ACCT is a holistic tool, bringing together multi-disciplinary teams to contribute to the manag : ment of an individual's risk, which may include mental health concerns, substance abuse a yd a range of other factors. The other support mechanisms described above also form part of the holistlc approach, alongside everyday interaction, support and challenge by staff. | have been copied to the response from the Tees, Esk and Wear Valley NHS Foundation Trust concerning the continuity of mental health care when healthcare stajf are absent so | will not repeat that information here. However, | can confirm that there is cujrently a review of continuity of mental health provision acrossithe women’s estate. Wark is ongoing to produce an action plan for each prison which will identify further progress required, the delivery of which will be overseen by the Deputy Director of Custody for the women’s estate. A Safer Custody summit meeting for the women’s estate is taking place on 1 February 2011/7, at which mental health provision will be one of the topics discussed. | You refer to your concern that the breakdown of delivery of aspects pf care to a prisoner, and the subsequent separate representation at inquests dilutes the concept of state responsibility. Healthcare services for prisoners in England are commissioned by NHS England as required by the Health & Social Care Act 2012 and set out in the NHS Mandai | This approach is regarded internationally as best practice, and the commitment to the approac' | was re-affirmed by recently in the white paper Prison Safety and Reform, alongside aurjcommitments to strengthen joint working arrangements between health commissioners and pfis bn governors in their co- commissioning relationship. NOMS works qlosely in partnership ith NHS England and Public Health England and a National Partnership fgreement sets out arrangements for joint governance and delivery alongside the roles and responsibilities af is ich agency. rs at risk of suicide or self- issued by NOMS in ensure that professionals with continuity of care, rs. In order to improve joined-up working to manage and support priso: harm, new guidance around mutti-disciplina working and ACCT we October 2016 and disseminated to all i The guidance aims t carefully consider a prisoner's care needs and that they are provided even when support will be delivered by different individuals or provid = At Low Newtan, the importance of effective integrated working is muiti-disciplinary forums exist to ensure close working between pro representatives from mental and physical health, midwifery, DART ( understood, and various ders. Meetings attended by Hrug treatment programme) and the Psychol o share details of clinical interactions and discuss complex cases Team take place dail diACCT reviews. In May 2016, Lo’ ewton Introduced a ‘complex case risk register’ to ensure that patients with complex mental }r physical needs were discussed on a weekly basis by members of the multi- from Tees, Esk and Wear Valleys NHS Foundation i if staff. Your final issue wording on the nicerns the wording in the Prison Service Instruction relating to ACCT and the hether this may create confusion as to the than more gene: Prisoners may e mood, recent hi designed to cap letter have been concerns that y elpful in providing some national context, as well as assurance that the have raised have been| addressed locally at Low Newton. Yours sincerely ee
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