Haydn Burton
PFD Report
Partially Responded
Ref: 2016-0346
1 of 2 responded · Over 2 years old
Sent To
Response Status
Responses
1 of 2
56-Day Deadline
29 Nov 2016
Over 2 years old — no identified published response
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
(1) The evidence in this case indicated that prison staff at Winchester Prison are not implementing ACCT plans in accordance with national policy notwithstanding the training they have received and in particular the observations conducted are inadequate therefore consider that the process and future training needs to be reviewed (2) The Prison Listener scheme rules as to prisoner confidentiality appeared to be confusing to the listener involved in this case. The HMP Winchester Listener Scheme Protocol dated October 2012 makes no reference to situations where an at risk" prisoner admits to having made active plans for suicide and threatens to self harm in the future (as in this case): consider the protocol for Listeners should make it another exception to the principle of confidentiality s0 that they can pass such information to prison staff and that Listeners should be trained to do s0 if they have reason to believe there is an imminent risk of suicide even if the prisoner is already subject to an ACCT_ Coroner'$ Office; Castle Hill, The Castle, Winchester, S023 8UL Tel 01962-667884 Fax 01962-667893 act July July
(3) The case highlighted the limitations of the NOMIS database in relation to recording details of closed ACCT plans meaning that prison staff are frequently unaware of important information about individuals gathered previously: The case showed that despite the national policy requiring Case Notes to be made of all ACCT plans this does not happen for all prisoners so that staff are ignorant even of the fact that there was a previous ACCT in place let alone the reason for it. The ACCT post-closure process should therefore be reviewed. consider this is particularly relevant where an ACCT is closed and the prisoner is later released and then re-imprisoned or is transferred to a different establishment.
(3) The case highlighted the limitations of the NOMIS database in relation to recording details of closed ACCT plans meaning that prison staff are frequently unaware of important information about individuals gathered previously: The case showed that despite the national policy requiring Case Notes to be made of all ACCT plans this does not happen for all prisoners so that staff are ignorant even of the fact that there was a previous ACCT in place let alone the reason for it. The ACCT post-closure process should therefore be reviewed. consider this is particularly relevant where an ACCT is closed and the prisoner is later released and then re-imprisoned or is transferred to a different establishment.
Responses
Response received
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Dear Mr Short Thank you for your Regulation 28 Report to Prevent Future Deaths addressed to HM Prison Service and The Samaritans, concerning the inquest into the death of Haydn Burton at HMP Winchester on 15 July 2015. Your report has been passed to the casework team in the Safer Custody and Public Protection Group (SCPPG) in the National Offender Management Service (NOMS) , as we have responsibility for the policy on suicide prevention and self-harm management and for sharing learning from deaths in custody_ The reply is provided after consultation with the Governor of HMP Winchester. note your concern that evidence at the inquest suggested that staff at Winchester are inconsistent in their implementation of the Assessment Care in Custody and Teamwork (ACCT) process, and that the practice of undertaking ACCT observations is inadequate_ am grateful to you for raising this concern_and would like to reassure you that the Governor of Winchester , is committed to ensuring that all operational staff are successfully trained in ACCT procedures to enable them consistently to follow national ACCT policy contained within Prison Service Instruction (PSI) 64/2011 Safer Custody: Local ACCT refresher training is due to take place on 13 and 20 December 2016 for 48 members of staff and will be delivered at least monthly thereafter HMP Winchester is also holding Safety Awareness on 21 December 2016. This local training will cover the whole ACCT process, including how to open an ACCT, and will consider lessons learnt from previous deaths in custody, including the requirement to ensure that the ACCT assessment is completed within 24 hours, the need to make appropriate mental health referrals , and the fact that ACCT case reviews must be multidisciplinary and attended by all those involved in the provision of care for the individual concerned. A plan is developed to deliver refresher training for ACCT case managers and assessors already in post, and to increase the number of staff trained in these roles_ In addition, more staff are being recruited, and 12 new Prison Officers are expected to complete the Prison Officer Entry Level Training (POELT) course that includes training on suicide and self-harm awareness and the ACCT process and start work at Winchester by March 2017 . Petty Day being
The Governor has recently introduced additional management assurance checks to ensure that staff are completing ACCT documents correctly and to the required standard, and that the appropriate level of care is given any person who requires to additional support provided during the ACCT process These assurance checks are completed by Orderly Officers, Duty Governors and the Safer Custody Team: The results are collated and will be discussed at the monthly Safer Custody meeting where trends will be identified and appropriate actions taken In addition quality assurance checks consider the role of ACCT Case Managers to confirm compliance, and identify any development needs_ ACCT Caremap actions are checked by the Safer Custody Supervising Officer and Custodial Manager who ensure that appropriate actions have been identified and taken forward. In addition to the multidisciplinary ACCT case reviews, Winchester now holds weekly multi-disciplinary ACCT meeting; attended by the Head (or Deputy Head) Of Safer Prisons, the Community Mental Health Team (CMHT) and the Offender Management Unit, where every prisoner who is subject to an ACCT is discussed, to ensure that important information and concerns are communicated to all relevant departments_ In your report you also suggested that the local Prison Listener Scheme Protocol include an additional exception to the confidentiality rules to allow Listeners (prisoners who are trained by the Samaritans to offer confidential and emotional support to other prisoners), to advise staff when prisoner confirms that have active plans to self-harm or threatens self-harm in the future_ As the Samaritans have set out in their separate response to your report, the principle of total confidentiality is central to their work, and applies equally to the work of Listeners This is reflected in the national partnership agreement between NOMS and the Samaritans that governs the operation of the Listener scheme and the NOMS safer custody policy set out in PSI 64/2011. In the light of this it is not appropriate for Winchester to adopt different policy on this point: Without the assurance of confidentiality, prisoners may not feel able to approach Listeners and talk freely in an atmosphere of total trust: Any change to this approach may lead to reduction in the number of prisoners accepting this vital source of support and sharing their concerns. Where a Listener believes that a prisoner is seriously at risk of suicide, the Listener actively encourages the prisoner to seek further help, and if do not wish or are unable to do so on their own, the Listener is trained to attempt to gain the prisoner's permission to alert staff to the need for help. You also raised your concern that NOMIS the prison case management system, is not used consistently to record details of ACCTs being opened and the reasons for so, and you suggested that the ACCT post closure process be reviewed. PSI 64/2011 requires staff to ensure that The closure must be recorded within the case notes section of NOMIS giving a brief summary of the relevant issues" (italics indicate mandatory requirement)_ The Governor at Winchester has introduced process whereby Wing Supervising Officers are informed each day of any ACCT post closure reviews which are due to be held, and provided with copies of the relevant ACCT plans: When the post closure interview has taken place, the ACCT is updated and returned to the Safer Prisons team to be filed within in the prisoner's core record. All Case Managers have been reminded of the importance of ensuring that the NOMIS case notes are updated following an ACCT case review, and are using the ACCT alerts on NOMIS to record the dates of an ACCT opened and closed_ The post closure process is now embedded and Winchester has seen significant improvements with regards to the completion of post closure ACCT reviews_ The will they they doing being
management assurance checks described above include sample checks of NOMIS following ACCT case reviews, and post closures reviews, and the prison is confident that there have been improvements in this area: hope this letter reassures you that the Governor of Winchester is taking steps to address your first and third concerns, and that; together with the separate response from the Samaritans, it explains why we will not be taking action in response to your second concern_
The Governor has recently introduced additional management assurance checks to ensure that staff are completing ACCT documents correctly and to the required standard, and that the appropriate level of care is given any person who requires to additional support provided during the ACCT process These assurance checks are completed by Orderly Officers, Duty Governors and the Safer Custody Team: The results are collated and will be discussed at the monthly Safer Custody meeting where trends will be identified and appropriate actions taken In addition quality assurance checks consider the role of ACCT Case Managers to confirm compliance, and identify any development needs_ ACCT Caremap actions are checked by the Safer Custody Supervising Officer and Custodial Manager who ensure that appropriate actions have been identified and taken forward. In addition to the multidisciplinary ACCT case reviews, Winchester now holds weekly multi-disciplinary ACCT meeting; attended by the Head (or Deputy Head) Of Safer Prisons, the Community Mental Health Team (CMHT) and the Offender Management Unit, where every prisoner who is subject to an ACCT is discussed, to ensure that important information and concerns are communicated to all relevant departments_ In your report you also suggested that the local Prison Listener Scheme Protocol include an additional exception to the confidentiality rules to allow Listeners (prisoners who are trained by the Samaritans to offer confidential and emotional support to other prisoners), to advise staff when prisoner confirms that have active plans to self-harm or threatens self-harm in the future_ As the Samaritans have set out in their separate response to your report, the principle of total confidentiality is central to their work, and applies equally to the work of Listeners This is reflected in the national partnership agreement between NOMS and the Samaritans that governs the operation of the Listener scheme and the NOMS safer custody policy set out in PSI 64/2011. In the light of this it is not appropriate for Winchester to adopt different policy on this point: Without the assurance of confidentiality, prisoners may not feel able to approach Listeners and talk freely in an atmosphere of total trust: Any change to this approach may lead to reduction in the number of prisoners accepting this vital source of support and sharing their concerns. Where a Listener believes that a prisoner is seriously at risk of suicide, the Listener actively encourages the prisoner to seek further help, and if do not wish or are unable to do so on their own, the Listener is trained to attempt to gain the prisoner's permission to alert staff to the need for help. You also raised your concern that NOMIS the prison case management system, is not used consistently to record details of ACCTs being opened and the reasons for so, and you suggested that the ACCT post closure process be reviewed. PSI 64/2011 requires staff to ensure that The closure must be recorded within the case notes section of NOMIS giving a brief summary of the relevant issues" (italics indicate mandatory requirement)_ The Governor at Winchester has introduced process whereby Wing Supervising Officers are informed each day of any ACCT post closure reviews which are due to be held, and provided with copies of the relevant ACCT plans: When the post closure interview has taken place, the ACCT is updated and returned to the Safer Prisons team to be filed within in the prisoner's core record. All Case Managers have been reminded of the importance of ensuring that the NOMIS case notes are updated following an ACCT case review, and are using the ACCT alerts on NOMIS to record the dates of an ACCT opened and closed_ The post closure process is now embedded and Winchester has seen significant improvements with regards to the completion of post closure ACCT reviews_ The will they they doing being
management assurance checks described above include sample checks of NOMIS following ACCT case reviews, and post closures reviews, and the prison is confident that there have been improvements in this area: hope this letter reassures you that the Governor of Winchester is taking steps to address your first and third concerns, and that; together with the separate response from the Samaritans, it explains why we will not be taking action in response to your second concern_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you HM Prison Service and (in relation to (2) only) The Samaritans have the power to take such action:
Report Sections
Investigation and Inquest
On 20 July 2015 | commenced an investigation into the death of Haydn James Burton, 42. The investigation concluded at the end of the inquest on 27 September 2016. The conclusion of the inquest was that Haydn Burton died as a result of hanging in his prison cell at HMP Winchester. The jury recorded that his mental state at the time was unclear and that it was not possible to rule out an impulsive as part of his personality disorder or as a means to bring attention to his perceived plight: This event was exacerbated by an inadequate implementation of ACCT policies and by insufficient communication between the various elements of the prison system_
Circumstances of the Death
Haydn Burton was detained in HMP Winchester as a convicted prisoner and had been made subject to an ACCT order at 09.30 on 14 July 2015_ He was found at 10.00 in the morning of 15 2015 having suspended himself from a ligature point in his cell (B3.30). Prison Officers , healthcare staff and ambulance staff resuscitated Mr Burton and he was transferred to Royal Hampshire County Hospital, Winchester where he died of the delayed effects of ligature suspension on 18 2015_
Copies Sent To
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.