Dear Mr Oliver Thank YOU for your report dated 15 December 2015 addressed, amongst others, to Michael Spurt, Chief Executive Officer of the National Offender Management Service (NOMS) and the Governing Governor of HMP Durham, concerning the recent Inquest into the death of Derek Thomas at HMP Durham on 28 August 2014. am responding on behalf of NOMS as Equality, Rights ad Decency Group has responsibllity for te policy on sulcide prevention and self-harm management and for sharing leamning from deaths in custody: have consulted with the Govemor at HMP Durham in formulating this response, which am copving to the other recipients ofyour report . Your report highlights a number of departures from correct procedure, and goes on to ralse concerns that: These circumstances [of 21 July 2014] were clearty very demanding but they were not unforeseeable and may be repeated in future: When the procedures were 'stress-tested' In the way were on 21 July 2014, they failed s0 that a SASH form went unnoticed: there Is a lack of appreciation by GEOAmey escort staff of the prisons reception procedures: There Is a lack of awareness by prlson staff of GEOAmey staff $ ignorance of them: Alteratively the prison reception staff develp the procedures without keeping GEOAmey staff Informed_ There Is an overreliance on the fidelity of the system, even when it has failed. No questlons were asked at any stage as to how a SASH form had arived In the prison without previousty noticed That the above concems are not addressed by, and g0 bevond, the Governors Notice to Staff of 8 December 2015 That the above concems go to the Inter-operabllity of GEOAmey ad prison ad healthcare procedures, which is not addressed by ay of the agencles am concerned that thls case provides paradigm example of not just fallure in communication between agencles but a deeper failure In properly appreclating each other procedures ad potential weaknesses where they are supposed to inter- connect _ they' belng yet

A number of steps have been taken t0 strengthen procedures, training and relationships between the agencies t0 address these issues Reception The Head of Operations at HMP Durham has instructed all staff working in reception that; prior to the escort contractor leaving the reception area, all documentatin must be physically checked and read: The PER and all documentation must be coss referenced It will be signed for by both A daily detail Is published which clearty identifies the members of staff who are working in reception on any given and these are retained The esort contractor has been informed of the process and Is aware that the warrant and the SASH need to be handed to the supervising officer and the PER an property t0 the offier: All staff working In reception are expected to be competent In all areas Of the process Both are situated side by side: A custodial manager and the Head of Operations will routinely observe this process As well as the above procedures, reception staff must verbally hand over any self-harm warnings t0 the officer the First Night Centre: Shoukd a prisoner be retuming from a court appearance the reception staff must verbally hand over this information directly to the health Oare staff: verbal hand over is In addition to the Health Care staff receiving all of the documentatin received on each prisoner: Training All staff working In reception must complete a kevel of tralning prior to working at the point in reception where prisoners are Initially recelved: The kevel of tralning available to reception staff Is an on-Iine course and a classroom based course: The Head of Operations at HMP Durham has deemed that as a minimum the on-line course must be completed: This will be managed by the Individual member of staff $ line manager: It wlli be added to their Individual learnlng path and monitored through the staff appraisal system Communkatbns between agencles The Head of Operations at HMP Durham meets with the escort contractor On a monthly basls: changes In procedures are communicated at this meeting; The entire contract Is managed by a NOMS monitor: Escort contractor managers make 0n-site visits to observe the process: There are seven Indivdual provlders that make Up the healthcare function: A monthly prison operational and clinical goverance meeting is hel and any Issues between the prison and healthcare cn be discussed at this meeting: note that your concems are wlder than the Issues covered In the Governors Notice to Staff of 8 December 2015, however yoU may be Interested to knOw that the NTS has been re- issued to primarlky target reception staff: outlines the importance of checking all documentation and advlses that & fallure to do so may result in disciplinary action: The Notice to Staff Is published on the bcal prison Intranet for period of tlme: It' Is also avallable on the shared drive: The Head of Operations will also be positioning thls on the front desk of reception for all staff working there to be constantly aware of. This will be followed up during staff s Individual performance reviews

Dear Sir Inquest touching the death of Derek Thomas Date of death: 28 August 2014 HMP Durham write in response to your report dated 15 December 2015 made under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. G4S Forensic & Medical Services (UK) Ltd took over responsibility for provision of healthcare services at HMP Durham on 1 April 2015. G4S Forensic & Medical Services (UK) Ltd is responsible for primary care and substance misuse care at HMP Durham ad employs team totalling in excess of 40 individuals made up of qualified registered general nurses; mental health nurses, substance misuse issues nurses ad healthcare support workers, together with separate administration staff; for this work: An organisation called Spectrum Community Health CIC is contracted separately to provide GP, specialist substance misuse GP and Pharmacy Services at HMP Durham: Mental health services at HMP Durham are provided by Tees, Esk ad NHS Trust: As part of its responsibilities, the mental health team is responsible for conducting mental health assessments The reception process at HMP Durham involves prisoners brought to the reception by escorts_ Each prisoner is received by prison officers and undergoes initial reception assessments and procedures Healthcare staff undertaking initial assessments of individuals arriving at the prison from court are not located in the reception building: The arriving prisoner undergoes the full reception process with prison officers before the initial healthcare assessment is undertaken Following completion of reception procedures, each prisoner is ready to be taken for initial healthcare assessment: At this point the prisoner is escorted by prison officers from the reception building to a separate building which houses the First Night Centre/Induction Wing: Wear Valley being building

documentation received with prisoner on arrival at the prison is taken by prison officers with the prisoner ad all of the documentation received with the prisoner is handed to the nurse undertaking the initial healthcare assessment. The reception procedure means nurses undertaking initial healthcare assessments rely on prison officers to provide them with the correct paperwork for each prisoner they are to assess. Healthcare procedures involve any Suicide/Self-Harm Warning Form (SSHWF) received for a prisoner being scanned onto SystmOne s0 that it forms part of the prisoner' s medical record: If the relevant section on the PER form is completed to indicate the presence of a SSHWF and this form does not arrive with the prisoner; then the nurse makes enquiries to locate the document The initial health screen involves the nurse completing an assessment covering all aspects of prisoner' s health using an approved NHS assessment tool on SystmOne The assessment is based on observations of the prisoners condition, behaviour and presentation, documentation and conversation with the prisoner: documentation is one element making up the overall assessment to ensure the prisoner is safe, not at immediate risk and is correctly referred for any additional support required. Mr Thomas' initial healthcare assessment notes information contained within the PER, including the correct nature of the offence; 4 previous incidences of self-harm and prior treatment for depression. Mr Thomas was referred by the nurse to a GP in relation to substance misuse issues The nurse undertaking the initial healthcare assessment is able to refer prisoners to number of support services following initial assessment; including the mental health team, a GP; the substance misuse team and counselling: On 22 July 2014, Mr Thomas was assessed by a GP, and; as a result; Mr Thomas was monitored by healthcare staff for 4B hours for signs of substance withdrawal: The records suggest had no concerns regarding suicide or self-harm risks All nurses working at HMP Durham are ACCT trained: If any nurse perceived a risk of harm to self for any prisoner then ACCT procedures would be commenced. The nurse who carried out Mr Thomas' initial healthcare assessment is a qualified mental health nurse ad substance misuse worker: It is the policy at HMP Durham to aim to have all initial healthcare assessments undertaken by qualified mental health nurses, unless there are circumstances preventing this. By arranging for initial assessments to be undertaken by qualified mental health professionals, this ensures full consideration of mental health issues during the assessments. The deceased's medical records indicate pertinent information contained on the PER, including risks relating to self-harm/suicide and mental health issues, was considered and noted by the reception nurse: The deceased was not considered at risk of self-harm at that time; based on the documentation; his presentation conversation and the nurse'5 observations This view was reinforced by the assessment by on 22 July 2014. On 24 July 2014, Mr Thomas attended court; It is my understanding court/escort officers did not at this time perceive any risk of suicide or self-harm and no SSHWF was completed. Further; Mr Thomas presented with no mental health or suicide/self-harm issues over a period of the next 4 weeks prior to his tragic death on 28 August 2014. Mr Thomas was seen by healthcare staff on 8 occasions prior to his death: There was no indication or notification to healthcare from any member of staff; visitor or professional visitor at any time whilst at HMP Durham that there were any suicide or self-harm concerns relating to Mr Thomas Client Confidential the Any the Any again

The following further steps have been taken to address your concerns surrounding other issues arising at the inquest:- nursing staff have been instructed to read/review all documents given to them pertaining to all patients when completing reception screening: at staff meetings/briefings, staff have been reminded of the importance of ensuring all paperwork and documentation relating to an individual accompanies that person following their arrival at the prison: trust my response addresses the healthcare concerns outlined in your recent report:

Dear Sir, RE: The inquest touching the death of Derek Thomas Deceased Response to Regulation 28 Report to Prevent Future Deaths am writing in reply to your letter dated 16th December 2015 containing the Regulation 28 Report to Prevent Future Deaths ("PFD Report") following the conclusion of the inquest touching the death of Derek Thomas Deceased which concluded on 14th December 2015. We are grateful to you for notifying us of the outcome of the inquest As you are aware Care UK Clinical Services Limited ("Care UK") ceased to be the providers of primary healthcare services at HMP Durham and for the North East cluster of prisons on 31st March 2015 and a5 of 1st April 2015 one of the providers appointed was G4S Medical Services who | note are also copied into your letter: In so far a5 healthcare are concerned it Is understood that during the course of Mr Thomas' reception and first night induction at HMP Durham the SASH was overlooked and a member of healthcare failed to read the history and events section of the PER: You also go on to discuss the inter-operability of agencies and a failure in communication between them and potential weaknesses where are supposed to inter-connect As above am unable to assist with regard to individual staff and local issues at HMP Durham as Care UK are no longer the healthcare providers. However with regard to some of the agencies Including GEO Amey and the prison service, where Care UK interact with them at other custodial facilities, will be forwarding your concerns to the heads of healthcare at those other facilities to highlight the concerns you have raised and to ascertain whether they are issues they have encountered, and if so what steps they can take: Cere UK Clinlcal Servlcas Umlted Regislered in Enpland No 03462881 Ropistered Offica; Connauaht House 850 Tha Crescenl, Colchester Businass Park, Colchaster, Essex CO4 908
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If you require any further information, please do not hesitate to contact me:

Dear Sir Derek Thomas Deceased We have reviewed your Regulation 28 Report and note your particular concerns at Sections 5(2) and 5(5) which directly relate to us. In respect of Sections 44 and B of Concerns raised over Circumstances of Mr Thomas' Death we have filed a statement from (Head of Compliance) dated 10 December 2015 which sets out the procedures, training in place regarding the completion of a Prisoner Escort Record ("PER") and a Self Harm and Suicide Warning Form ("SASH Form ') and the new PER being piloted. We attach further copy of this statement. We refer you to paragraph 15 of statement: GEOAmey escort and court officers are undergoing refresher training regarding the completion of a PER: At 31 January 2016 1,911 officers out of 2,102 officers (90.91%) had received this training including the officer who completed Mr Thomas" PER on 21 July 2014. The Coroner'$ Concerns (Section 5) Procedure (Section 5(2)) are private contractor carrying out prisoner escort and custody services across the UK pursuant to a contract with the Ministry of Justice ("the MOJ"). We refer you to paragraphs 3, and 7 of Mr Airey'$ statement which set out the relationship between the various bodies involved in prisoner detention and escort, and the Prison Service Orders ("PSOs") , Prison Service Instructions ("PSIs") and Standard Operating Procedures ("SOPs ) we adhere to. The escort of prisoners from Court to designated locations (e.g. prison) is set out in the contract with the MOJ: On delivering prisoner to prison our escort officer has to hand over the prisoner's Warrant or Court Order (or faxed Warrant if agreed) , property, official records including PER (which must be fully completed with that day's proceedings) and other documentation, and any medication in their possession for the prisoner' $ use. The escort officer has to ensure that the receiving officer endorses each prisoner s PER and their property, cash, official records and any other accompanying documentation: The contract does not stipulate particular prison's procedures; it states the paperwork to be handed over on the delivery of a prisoner. Page of 4 We

Geoamey The escort officer who escorted Mr Thomas to HMP Durham on 21 July 2014 handed over to the reception officer Mr Thomas Warrant, PER and SASH Form, F205O and his property and paperwork: The reception officer endorsed Mr Thomas" PER: Whilst it is accepted that the escort officer made omissions o the PER, it is apparent on reading it that comments had been received from Mr Thomas barrister on 21 July 2014 regarding a potential self-harm risk and a SASH form had been commenced on Mr Thomas. The reception officer who signed the PER accepting Mr Thomas into HMP Durham custody stated whilst giving evidence at the Inquest that had not read the content of the PER as the front sheet had not indicated that there was SASH Form enclosed. This is contrary to the PSOs and PSIs in place_ PSO 1025 sets out the mandatory instructions and guidance for PER completion: The PER ensures that escort staff and receiving agencies have information (particularly a prisoner'$ risks) regarding prisoner to and escort and it ensures consistency across multi-agency use on national level. Section 4.13 states that after checking all details on the PER the receiving officer completes the "record of handover" and signs the form and the escort officer retains the bottom copy of the PER Further, PSI 74/2011 states that completed PER must be examined in prison reception "to identify any immediate needs and risks already recorded" and the prisoner must be interviewed to discover and record any further immediate needs and risks and any other information about the prisoner that may be relevant (paragraph 2.15). The PER and any other available documentation including the SASH Form must be examined and prisoner interviewed in prison reception to assess the risk of self-harm or harm to others as part of the Cell Sharing Risk Assessment (paragraph 2.18). The information is recorded and shared with other departments and agencies (e.g: Healthcare) internally and externally and actions taken are to be documented (paragraphs 2.19 and 2.20). We have no remit over HMP Durham staff (who are MOJ employees) and their compliance with the PSIs. The prison reception officers gave evidence at the Inquest that the SASH Form had not been handed to them on US delivering Mr Thomas to HMP Durham ad had been handed in at later time: The Jury, however, accepted the escort officer'$ evidence that the SASH Form had been handed over to the reception officer on delivering Mr Thomas to HMP Durham o 21 January 2014. This evidence was supported by us having in our archives a pink carbon copy of the SASH Form and the top copy of the SASH Form being found on Mr Thomas' prison file at HMP Durham following his death: Each prisoner'$ paperwork is handed over to the prison reception staff separately: The escort officer's evidence was that on the right hand side of the reception desk at HMP Durham they handed over the prisoner'$ Warrant and F2050 to reception officer and on the left hand side of the desk they handed over the PER, SASH Form (if one existed) and property record to another reception officer and said what documents they were handing over. If SASH form was handed over would say to the reception officer that needed to read it. The escort officer is not permitted to leave reception until the reception officer has reviewed and signed all the necessary paperwork, passed back the PER and SASH Form carbon copies (stapled together) and informed the escort officer that they can leave We would place the carbon copies the documents with the VOR for the and place them in our archives: The prison would retain the original documents and place them on the prisoner prison file_ The reception officers' evidence, however , was that the Warrant and the SASH Form would be handed to the reception officer on the right-hand side of the desk and the PER and the property would be handed to the reception officer on the left hand side of the desk which was located through an archway. The HMP Durham reception process, as stated by the reception officers giving evidence, is peculiar as it is requirement on the PER to indicate that SASH Form is "enclosed" (i.e: contained within). As far as we (and our officers) are concerned, at the time of Mr Thomas' escort to HMP Durham on 21 July 2014 and until the reception officers gave evidence at the Inquest, there was no lack of appreciation by GEOAmey officers of HMP Durham'$ reception process We were not aware of a different process. In fact the reception process followed today o delivering prisoners to HMP Durham is the same as stated by the escort officer. If HMP Durham has devised its own reception

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Geoamey process, HMP Durham staff should inform our escort officers on arrival of its process and instruct them as to whom the documents should be passed to on reception: There are 207 prisons from/to which we collect/escort 1,000s of prisoners per week: We also collect /escort prisoners from/to 10Os of Courts, Police Stations and Detention Centres across the UK: It is not feasible for uS to request from each establishment, norfor it to draw Up, specification sheet for individual operating processes: It would create an significant volume of paperwork for our officers: Inter-operability of Agencies (Section 5(5)) The Home OfficelMOJ We appreciate other agencies' procedures and have devised and revised our SOPs to comply with the HM Prison Services requirements set out in the PSOs and PSIs. We engage in dialogue with other agencies (where possible) to develop best practice, procedures and documentation to be shared between the agencies: where required, can contact the Prisoner Management Unit ("PMU"), to obtain information and assistance on the location of suitable prisoner accommodation: We have a system in place to ascertain the number of prisoners collected from Police premises and prisons on given and identify the number of custody beds required. We inform PMU of the requirements by 08:00 hours on that and provides them with hourly updates from 12:00 hours to 17:00 hours. As noted at paragraph 17 of Mr Airey's statement, we are audited externally by Prisoner Escort and Court Services ("PECS") to ensure it is complying with the MOJ contract: These audits are not pre- determined; PECS will arrive to carry out a audit unannounced_ The PER was introduced in May 2009 having been agreed by all agencies involved in prisoner movements. We were not involved in the discussions aS our contract with the MOJ not commence until August 2011. As has been referred to at paragraphs 19 to 28 of Mr Airey's statement, the Home Office has devised a new PER which is being piloted. We are undertaking a formal evaluation process and shall provide feedback to the Home Office about the pilot programme: The final say on policy, procedures and documentation is with the MOJ to whom we are contracted: Healthcare We do not have any contract, dialogue or contact with the Healthcare provider at HMP Durham nor with any Healthcare provider at any prison across the UK The contract for the provision of Healthcare facilities and the policies and procedures in place is between the MOJ and the Healthcare provider. We have no input into this_ We are aware that on prisoner's arrival at prison he should be assessed by Healthcare as part of the First Night Procedure during which the PER should be read. Mr Thomas was seen by Healthcare on his arrival to HMP Durham: It was acknowledged by those giving evidence on behalf of Healthcare at HMP Durham that the PER (containing Mr Thomase risk indicators) was with the documentation sent down to Healthcare from reception but the PER was not read by them as the front cover had not been ticked to state that SASH Form was enclosed: On assessment by the nurse self-harm and suicide factors were noted: Mr Thomas was also assessed by Healthcare on a daily basis up to 24 July 2014 to monitor his alcohol withdrawal: 3 of 4 We, day likely day Page

Geoamey It is unclear what further inter-operability could be put in place other than the correct completion of the PER by our officers (and/or others) and the reading of PER and SASH Forms by the prison and the Healthcare provider: Accordingly, we are of the view that the system is not "dysfunctional' We have taken your concerns on-board: We refer you to Mr Airey'$ statement: There has been no change to our procedures regarding the SASH Form or the PER: Following this Inquest there has been no request by the MOJ or PECS for our procedures to be revised: We remain of the view that we have the correct procedures and systems in place for the safe custody and escort of prisoners and the Jury'$ conclusion and your concerns regarding the company can be properly addressed by the additional focused training in place which has been completed by over 90% of our officers with the remaining officers to complete it as soon as possible: