Dear Mr Wlliams Thank You for your Regulatlon 28 report dated 21 September; addressed Ip boin the Govemor of HMP Hewell and Worcestershire Health and Care NHS Trust concernirg the recent inquest into the death %f Liam Smith who died on 17 August 2014 Your repor has been passed to Ihe Equality, Rights and Docency Group {ERDG) In the National Offender Management Service (NOMS) as we have responsibility for the policy on suicide prevontion and self-ham management and for sharing leaming deaths (n custody, This reponse is provided on behali of NOMS, the Govemor of Hewell and the Worcestershire Health and Care NHS Trust have addressed the points You have made in the order that were raised, Evidence suggested that Mr Smith was at risk of Inadvertent self harm and that therefore in accordance with PSI 64/2011 ACCT procedures ghould have been opened In respect of him Witnesses confirmed their understanding of that mandatory requirement but indicated that wouid use their ctinical judgoment In deciding whether or not to open an ACCT Itis of concern that staff may therefore not be following mandatory PSI ingtructions and thal prisoners are not 'receiving apprapriate protection by way of the ACCT process; As You are aware chapter 5 of Prison Service Instruction (PSI) 84/2011 sets out the policy on the Assessment, Care in Custody ard Teamwork (ACCT) process ACCT is a prisoner- centred; flexible care Planning approach which is used in all prisons to Manage & prisoners nbk Dr self-ham or suicide; Managing suicide and self-harm risk within the prison estate is a difficult and complex Issue , #tis recognised that many prisoners present with & number of static and dynamic risk factors that may lead to them being more susceptible to risk of se f-han; such as substance misuse, childhood adversity or mental health is8u88 Prisoner; who Is Identified as at risk, Must be managed and supported using the ACCT procedures Staff are often required to take difficult decisions and make judgements about a prisoner's rsk of harm based on 8 number of factors It Is Important that & full as8essment of & prisoner's risk is undertaken including input clinicians in order to make a fully infoned decision about a prisoners risk to themselves which will infan the decision as to whother an ACCT document should be opened Petty from they they Any belng from

Additicnally; the policy states that f a member of staff recaives information which may indicate 2 risk Must ofen an ACCT. It is not the intentlon of the policy Io requlre statf to open an ACCT automatically in every circumstance wnere a risk 'may" be indicated but it i5 expected that communicale their concems immodiately I0 Ihe Residential, Doily Or Night Operational Manager, andor considor oponing an ACCT Plan and makc 0 record of their decision in an appropriale source 8.3 obscrvation book NomS A review of tte ACCT process is currently ongoing; which will inform changes to the current policy In PSI 64/2011 2 Evidence was given that certain medical information which arrived at the prison with Mr Smith was not disseminated to those in reception or those who later had doalings with him which meant that were Vnaware of the potential risk of suicide %r self harm It wab suggested by some witnosses that documentation "gpes astray" is only fcund much lator; It is accepted that the reception processes in relation Io communicating with escort staff were not 38 robust as ideally shculd have been. Both the prison and healthcare provider have reviewed their procedures in roception t0 ensure that systems are in place thal communication between reception 8taff and the escort provider Is recorded appropriately, In Mr Smlth $ case It appears that the Person Escort Record (PER) was not used appropriately; in that the medical in confidence information provided by heatth care profossionals In the coun was not attached to PER Healthcare Staff indicated Ihat do not always read relevant sections of the Systm notes and that the "summary page of Systm does not always "PUII through" relevani information wlth a result that staff be unaware of that Information_ The concerns you have raised regarding healthcare staff nct reading rolovant sections of the records have been taken seriously All reglstered cilnical staff have @ professional obligatlon t0 review relevant parts of the notes; this message has been reiterated ard addressed with all clinical staft, The second part of Ine concern relates to infcrmation being 'pulled through' onto the summary page This matter Is being taken to the West Mldlands Regional SystmOre User Group 80 that the learning generated through Mr Smith's death can bo shared much wider tnan one prison: In the meantlme, this isxue has beun ralsed with clinical staff in a statf meeting at HMP Howoll and the learning is dissominated acros? three prisons In which the Trust provides healthcare Evidence suggosted only limited Interaction between members of Healthcare Staff and prigoners who were deemed as "high risk drug users" with a concern that waming signs are miszed The Trust has confrmed that they now changed their practices relating to high risk users. The initial contact for those undergoing any type of detoxification Is the cageworker who has contaci the atter the person j8 received into the prison_ Additionally a follow Up ledger to SystmOne has been introduced wlthin three working days of the dotoxiication programme ending An audit will be undertaken within the first quarter of 2016 t0 check that the processes are working offectively; hope You the contents of thls letter have been helpful in providing some national context and additional assurance that the concems that you have raised have Ceen, or are being; addressed locally at HMP Hewell note that you have provided & cCpy of your lptter I0 (and land we shall be obliged If You could kindly forward t0 Ihem a COpy Orour response Wvo dD consider they they they they the they may very being the have drug from day We We

i may De useful I0 share our response_with the Chief Coroner in light of the national implications of the revision of the relevant PSI;