Richard Walsh
PFD Report
All Responded
Ref: 2016-0377
All 4 responses received
· Deadline: 23 Apr 2017
Response Status
Responses
4 of 3
56-Day Deadline
23 Apr 2017
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
In the circumstances it is my statutory to report to you: 1. The expert psychiatrist gave an opinion that there was a defect in the system of communications between professionals and agencies involved in the care of Mr Walsh: There appeared to be not only serious failures of communication, but failurcs inadequate processes of communication between custodial and health professionals, between police, court; health care and prison services, that progressively crucial information about the risks and needs of the deceased as he passed through different hands. The expert described what staff knew at HMP Belmarsh as diluted and grossly distorted. Evidence heard is listed: Those conducting the MHA assessment did not discover that; on the very evening of the assessment; the police had been in contact with the deceased mother, who had information about his mental health, nor did examine the custody record or nor consult the Detained Persons Medical Forms, which one described as usually containing little useful information. The Custody officers and MHA assessors never spoke.
6) The AMHP said that the Mental Health Act (MHA) assessment was put on RIO system for Hampshire NHS staff; and could be made available to general practice Or healthcare on request; but was not automatically transferred. There was a need for a national process of information sharing: c) The Custody Advisor informs the court that the national system was that the Detained Person's Medical Forms (DPMFs) were routinely scanned onto the police RMS system, but the Mental Health Act Assessment is not: The logic was not apparent; as both would appear to have the same quality of confidence. Medical in confidence information police stations was sometimes transmitted in sealed envelopes marked Confidential, travelling with the prisoner, but the independent psychiatric expert thought that this was the least effective form of communication and recommended that the assessing team should communicate with the next stage in the process, such as contacting the catchment area forensic service by phone out of advising that the prisoner is likely to go to a particular court; and writing a letter with the assessment in office hours. The Police Custody Advisor said that he would not expect the Mental Health Act day: days hung day, will duty from lost key log, prison from hours,
Assessment report to routinely go to the court or prisons with the Prisoner Escort Record (PER), unless the prisoner was sectioned. The logic for this was also not clear; as the non sectioned patient was more at risk of not having appropriate mental health care non communication, than the sectioned one. e) No report or letter or appropriate communication about the MHA assessment was completed in the police station to subsequent health care providers, nor was there a system to require it: f) There was no evidence that the police doctor (FME) and police nurses notes, called Detained Person's Medical Forms (DPMFs) were ever seen by anyone with responsibility for Mr Walsh in Highdown or Belmarsh prisons, nor evidence of any established process of transfer of the information: Prison staff said that medical in confidence information can be scanned to prison health care, but there was not an established system of 'securing medical records from police stations. The Pre-Release risk assessment was completed by a custody officer, indicating that the deceased had no risks. The Custody Advisor indicated that the officer did not appear to understand the system, as this particular questionnaire in the custody record should not have been completed for transfer to court: But it appeared that its negative entries may have misled others assessing risk at time of transfer h) The completion of the PER in the police station did not reflect the contents of the custody record or custody failing to record his attempt to commit suicide by dehydration, his delusions, his obsession, or that he had been assessed as high risk of suicide. The Custody Advisor said that the system was meant to be that the PER was signed off by the custody officer; who should have known that the information was incorrect: i) The police staff completing the PER indicated she routinely did this without consultation with the custody log Or custody record, which was not required, although the Custody Advisor informed the court that this was not meant to be the system. j) The care plan at the police station which was recorded in detail in the custody record (and is meant to record any risks and evidence of mental illness) was not sent onwards with the PER, nor was the section on the PER marked Care Plan completed, as the Custody Advisor informed it should be. Staff informed the court it never is. k) Staff at the first night centre assessment at HMP Highdown saw the basic information about his offence and recent history and the police national computer printout with no markers, although a subsequent one was found with markers, indicating a previous attempt in custody to himself in custody and a threat to stab anyone who takes his children. There was no cxplanation for a false negative sent: from 1og, - hang being
1) It is not clear if the nurse the health screen at HMP Highdown was shown or looked at the PER from the police station: m) It is not clear whether the nurse assessing health fitness for segregation in HMP Highdown by completing a proforma, did consult the System One Medical Records, but the nurse that he had no information on the prisoner'$ behaviour and health in the police station, nor over the preceding four weeks, which he needed, and that he expected the reception nurse to information to him and it was not for him to go to Reception to get it: n) The PER completed at HMP Highdown did not even reflect the limited information had received from the police station three earlier. It recorded no current health risks although the previous PER from the police station had indicated non compliance with MHA assessment and depression, a GP letter received reported a previous overdose in February and the decision had been made in reception that he needed mental health in reach service: The health care officer just recorded "fit for transfer"
0) The prison officer conducting the first night centre assessment in HMP Belmarsh did not see or consider the PER from police station to HMP Highdown, three previously: He did know he had a serious charge coming Up for sentence and had no family support and was going to be isolated for 23 Vz hours a in a single cell. He did not know he was depressed and on antidepressants, and if he had he would have opened an ACTT: Yet this information was known to health care staff: He reports that the nurse told him of no concerns and he told her of none: p) It was not apparent that the first night nurse assessment in HMP Belmarsh knew of or included consideration of his status on a care regime' which isolated him for his protection from other inmates. The nurse did not feel there was time nor was it his to review the medical records. He completed his proforma recording what the prisoner replied, even though he had information that it may be untrue and did not regard it was his to record or reconcile differences. The reception GP assessment in HMP Belmarsh did not consider his status isolated on a care regime although it was risk factor; nor had any knowledge of his behaviour in the police station or see any relevant information PNomis or discipline staff.
1) The GP the GP assessment in HMP Belmarsh informed the court that there was insufficient time in his to revicw the inmate medical records. He that the records showed that suicide six risk factors listed in Early Days in Custody were present recent change in circumstance, transfer another establishment; violent offence,history self harm and suicide,potentially category doing agreed bring days they days day 'duty job job agreed duty from doing job agreed
Aand history of mental illness and O1 alcohol problems. He had neither been informed of these factors nor identified them from the records and s0 neither opened an ACCT nor referred him to a psychiatrist: He was referred to the MH in-reach team by the nurse. That team reviewed his medical records, showing a history of alcohol abuse and depression on treatment (which did not apparently include any from the police station, which the psychiatrist said he does not routinely see) and were reassured by his not being followed up by a psychiatrist in the community after previous psychiatric admission, and by his presentation not raising any concerns for almost all the doctors and nurses, who had seen him in prisons. did not see any PERs, and was not informed he was isolated in a of care regime for 23 Vz hours a nor that the victims were children. The decision not to conduct a psychiatric assessment would have been different if he had scen the PERs or DPMFs or MHA assessment; or his in patient psychiatric notes The independent psychiatrist gave an opinion that the loss of information was a particular concern as people move in and out of custody so that there was a potential that information would be lost to the civilian GP. Whilst some organizations had taken a number of stcps to minimize the risks to the lives of others, particular the development of a national PER, others had only awoken to the risks in the closing days of the inquest: Virgin Health Care chose not to attend; Southern Health and Oxleas NHS Trust submitted plans to prevent future deaths before the inquest concluded. Hampshire Constabulary reported changes in training and staff awareness. Hampshire County Council prepared a short document of proposed actions, but it was not available as evidence as it was received by the court after the conclusion of the evidence: The evidence taken as a whole, suggested that there was a breakdown of communication at every professional and organizational interface, 18 of which are illustrated above. There was n0 system for transfer of health care information from police station court; or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or it if it was not in possession, whether there was also one to ask for it and if s0 which individual bore that responsibility: There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system; by rote with either no time to consider the whole person, O1 no sense that it was their responsibility to consider missing or discordant information Or to be proactive in communicating gaps in knowledge Or concerns. From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened.
2. That the standard of Mental Health Act assessments by these individuals needs to be improved, and, given all three were in agreement; that also training and provision for MHA assessments in police stations more widely may need to be reviewed_ drug They 'duty being day, key agreed complete
3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment o choice of assessors that mean that prisoners go to segregation when should be in the health care wing, or that go without observation, when they should be onan ACCT and receive extra support:
6) The AMHP said that the Mental Health Act (MHA) assessment was put on RIO system for Hampshire NHS staff; and could be made available to general practice Or healthcare on request; but was not automatically transferred. There was a need for a national process of information sharing: c) The Custody Advisor informs the court that the national system was that the Detained Person's Medical Forms (DPMFs) were routinely scanned onto the police RMS system, but the Mental Health Act Assessment is not: The logic was not apparent; as both would appear to have the same quality of confidence. Medical in confidence information police stations was sometimes transmitted in sealed envelopes marked Confidential, travelling with the prisoner, but the independent psychiatric expert thought that this was the least effective form of communication and recommended that the assessing team should communicate with the next stage in the process, such as contacting the catchment area forensic service by phone out of advising that the prisoner is likely to go to a particular court; and writing a letter with the assessment in office hours. The Police Custody Advisor said that he would not expect the Mental Health Act day: days hung day, will duty from lost key log, prison from hours,
Assessment report to routinely go to the court or prisons with the Prisoner Escort Record (PER), unless the prisoner was sectioned. The logic for this was also not clear; as the non sectioned patient was more at risk of not having appropriate mental health care non communication, than the sectioned one. e) No report or letter or appropriate communication about the MHA assessment was completed in the police station to subsequent health care providers, nor was there a system to require it: f) There was no evidence that the police doctor (FME) and police nurses notes, called Detained Person's Medical Forms (DPMFs) were ever seen by anyone with responsibility for Mr Walsh in Highdown or Belmarsh prisons, nor evidence of any established process of transfer of the information: Prison staff said that medical in confidence information can be scanned to prison health care, but there was not an established system of 'securing medical records from police stations. The Pre-Release risk assessment was completed by a custody officer, indicating that the deceased had no risks. The Custody Advisor indicated that the officer did not appear to understand the system, as this particular questionnaire in the custody record should not have been completed for transfer to court: But it appeared that its negative entries may have misled others assessing risk at time of transfer h) The completion of the PER in the police station did not reflect the contents of the custody record or custody failing to record his attempt to commit suicide by dehydration, his delusions, his obsession, or that he had been assessed as high risk of suicide. The Custody Advisor said that the system was meant to be that the PER was signed off by the custody officer; who should have known that the information was incorrect: i) The police staff completing the PER indicated she routinely did this without consultation with the custody log Or custody record, which was not required, although the Custody Advisor informed the court that this was not meant to be the system. j) The care plan at the police station which was recorded in detail in the custody record (and is meant to record any risks and evidence of mental illness) was not sent onwards with the PER, nor was the section on the PER marked Care Plan completed, as the Custody Advisor informed it should be. Staff informed the court it never is. k) Staff at the first night centre assessment at HMP Highdown saw the basic information about his offence and recent history and the police national computer printout with no markers, although a subsequent one was found with markers, indicating a previous attempt in custody to himself in custody and a threat to stab anyone who takes his children. There was no cxplanation for a false negative sent: from 1og, - hang being
1) It is not clear if the nurse the health screen at HMP Highdown was shown or looked at the PER from the police station: m) It is not clear whether the nurse assessing health fitness for segregation in HMP Highdown by completing a proforma, did consult the System One Medical Records, but the nurse that he had no information on the prisoner'$ behaviour and health in the police station, nor over the preceding four weeks, which he needed, and that he expected the reception nurse to information to him and it was not for him to go to Reception to get it: n) The PER completed at HMP Highdown did not even reflect the limited information had received from the police station three earlier. It recorded no current health risks although the previous PER from the police station had indicated non compliance with MHA assessment and depression, a GP letter received reported a previous overdose in February and the decision had been made in reception that he needed mental health in reach service: The health care officer just recorded "fit for transfer"
0) The prison officer conducting the first night centre assessment in HMP Belmarsh did not see or consider the PER from police station to HMP Highdown, three previously: He did know he had a serious charge coming Up for sentence and had no family support and was going to be isolated for 23 Vz hours a in a single cell. He did not know he was depressed and on antidepressants, and if he had he would have opened an ACTT: Yet this information was known to health care staff: He reports that the nurse told him of no concerns and he told her of none: p) It was not apparent that the first night nurse assessment in HMP Belmarsh knew of or included consideration of his status on a care regime' which isolated him for his protection from other inmates. The nurse did not feel there was time nor was it his to review the medical records. He completed his proforma recording what the prisoner replied, even though he had information that it may be untrue and did not regard it was his to record or reconcile differences. The reception GP assessment in HMP Belmarsh did not consider his status isolated on a care regime although it was risk factor; nor had any knowledge of his behaviour in the police station or see any relevant information PNomis or discipline staff.
1) The GP the GP assessment in HMP Belmarsh informed the court that there was insufficient time in his to revicw the inmate medical records. He that the records showed that suicide six risk factors listed in Early Days in Custody were present recent change in circumstance, transfer another establishment; violent offence,history self harm and suicide,potentially category doing agreed bring days they days day 'duty job job agreed duty from doing job agreed
Aand history of mental illness and O1 alcohol problems. He had neither been informed of these factors nor identified them from the records and s0 neither opened an ACCT nor referred him to a psychiatrist: He was referred to the MH in-reach team by the nurse. That team reviewed his medical records, showing a history of alcohol abuse and depression on treatment (which did not apparently include any from the police station, which the psychiatrist said he does not routinely see) and were reassured by his not being followed up by a psychiatrist in the community after previous psychiatric admission, and by his presentation not raising any concerns for almost all the doctors and nurses, who had seen him in prisons. did not see any PERs, and was not informed he was isolated in a of care regime for 23 Vz hours a nor that the victims were children. The decision not to conduct a psychiatric assessment would have been different if he had scen the PERs or DPMFs or MHA assessment; or his in patient psychiatric notes The independent psychiatrist gave an opinion that the loss of information was a particular concern as people move in and out of custody so that there was a potential that information would be lost to the civilian GP. Whilst some organizations had taken a number of stcps to minimize the risks to the lives of others, particular the development of a national PER, others had only awoken to the risks in the closing days of the inquest: Virgin Health Care chose not to attend; Southern Health and Oxleas NHS Trust submitted plans to prevent future deaths before the inquest concluded. Hampshire Constabulary reported changes in training and staff awareness. Hampshire County Council prepared a short document of proposed actions, but it was not available as evidence as it was received by the court after the conclusion of the evidence: The evidence taken as a whole, suggested that there was a breakdown of communication at every professional and organizational interface, 18 of which are illustrated above. There was n0 system for transfer of health care information from police station court; or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or it if it was not in possession, whether there was also one to ask for it and if s0 which individual bore that responsibility: There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system; by rote with either no time to consider the whole person, O1 no sense that it was their responsibility to consider missing or discordant information Or to be proactive in communicating gaps in knowledge Or concerns. From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened.
2. That the standard of Mental Health Act assessments by these individuals needs to be improved, and, given all three were in agreement; that also training and provision for MHA assessments in police stations more widely may need to be reviewed_ drug They 'duty being day, key agreed complete
3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment o choice of assessors that mean that prisoners go to segregation when should be in the health care wing, or that go without observation, when they should be onan ACCT and receive extra support:
Responses
Response received
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Dear Sir Inquest touching the death of Richard Walsh We are providing this letter in response to the Coroner's Regulation 28 Report to Prevent Future Deaths ("Regulation 28 Report"= issued pursuant to Regulation 28 and 29 of the Coroner's (Investigations) Regulations 2013 dated 25 October 2016 Within the Regulation 28 Report; we note the Coroner states that 'Virgin Health Care chose not to attend" From the outset we would like to that Virgin Care Services Limited ("Virgin Care") did in fact attend the Pre-Inquest hearing which took place on 16 August 2016 and it was recognised that the deceased was remanded within HMP High Down for 3 days, where Virgin Care provide some but not all of the healthcare services_ Legal Counsel made submissions that; given Virgin Care's limited involvement; witnesses could attend, the Inquest to provide evidence, but that there was no requirement for Virgin Care to be listed 'as an Interested in this matter, saving both healthcare time and costs. The Coroner agreed with this approach: Subsequently, two witnesses attended the Inquest on behalf of Virgin Care on the requisite days of the 3 week Inquest and gave evidence. As a result of the Regulation 28 Report; the Coroner has requested that Virgin Care provide their response to Matter 3 in respect of the Coroner's Concerns: That the inadequacy of the nurse assessment of fitness for segregation in HMP High Down is a risk was not ACCT trained and it appeared that he was unaware of PSI
1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of accessors that mean prisoners go to segregation when should be in the health care wing, or that go without observation, when they should be on an ACCT and receive extra support" Virgin Care has been "asked to consider whether the process Is fit for purpose or whether redesign or further training is indicated" We respond as follows: Response The Coroner has recognised that the Nurse involved in this Inquest was not ACCT trained and unaware of PSI 1700. We accept the Coroner's recognition of events and can advise a8 follows. We attach as Appendix A a copy of the "Induction Checklist" for HMP High Down healthcare colleagues. This protocol sets out the induction programme which all healthcare colleagues are required to complete whilst are supernumerary_ This relates to a four week period where work supervised at all and so are not considered within staffing numbers for off purposes. Pages Virgin Care w; Www vireyinc?ue €.uk rRetgisIered diiicc; Virgi;: (Hals: Siruvi,es jnbnu tnt: 12Tavi;x %u:e_ 'xW' Wcihai)_ 5{jistxr(E i $.iex eis | PQ} W uae iJimnt04 0/80- Dale; 19/12/2016 v1.o RECEIVED clarify Party they they they they times duty
virgincar NHS one to three inclusive of the protocol set out a timetable for the expected timeframe for different areas of learning to be covered. The items on page three are expected to be completed within the first month of an individual commencing work at HMP High Down: Item 15 on page three of the induction checklist is "ACCT Awareness". This is current practice and was at the time of the death of Mr Walsh_ The induction process had been redrafted prior to the death but after had started and therefore the Nurse accurately reflected in his evidence that he had not received this ACCT training within his induction. HMP High Down prison colleagues are responsible for the formal training of all colleagues (including those in healthcare) in the ACCT Awareness process. During induction, an overview of the ACCT process is provided and colleagues are made clear the expectations of healthcare staff as of the ACC process. Within this training session, the importance of the ACCT process is conveyed and the attendance of Virgin Care colleagues attending the formal training provided by the prison is emphasised Following the induction ACCT awareness training, colleagues are required to sign to say they are satistied that they have received satisfactory ACCT awareness training; their line manager is also required to sign to say they are confident the new colleague is capable of applying their training and has understood_ In addition; on completion of their induction, arrangements are made for healthcare colleagues to sit in as an observer with experienced members of staff at an ACCT review meeting: This will ensure that new members of staff will not be required to take part_in an ACCL review untiL they_have_seen how the review meetings proceed Since the induction pack was introduced Algorithms" or alternatively "Fitness_for_Segregation" forms are also part of the Virgin Care Induction pack for healthcare colleagues at HMP High Down_ During induction these are scrutinised between staff and their Iine manager. At the conclusion of the training, the member of staff will sign, and thereby declare, that have received relevant training before their induction is completed and are able to work independently: As part of the_training; Virgin Care healthcare colleagues undergo scenario-based_training to allow them to practice completing and signing "Fitness for Segregation" forms_ An example of the form is attached at Appendix B_ Again; this is confirmed by the manager signing to say confident that the new colleague has understood and has demonstrated their competence during the scenario-based training: The Coroner considered at the Inquest that that the Fitness for Segregation form was not completed accurately by in the case of Richard Walsh: However, having reviewed the documentation as part of our response to the inquest, we consider that had completed this form correctly and the information he had at his disposal meant that this gentleman was fit for segregation: The patient was further reviewed by another nurse who also deemed him fit for segregation appears to have been led to doubt himself at the inquest. Since the Inquest, Virgin Care has arranged additional ACCT awareness training_with the HME High Down's_Safer Custody department to ensure all current healthcare colleagues receive training in next few weeks and this will be completed by the end of January 2017_ Once all colleagues have received initial or refresher training, this will be monitored on the colleague training log and relevant line managers will ensure all staff are given refresher training at least annually. Virgin Care WiWW Vinghcaxre,},lua Relji fareri aHiic;c; Vegin: (Gtia Sivicn; ~illoai |oixsn: 1XTavislrk: F quxhne? Vhxcim' Wi ime Kqsicnwvcl Exhulai%c} aiX Walxg; Naunizci 07255747/ Date: 19/12/2016 vi. part "Seg they they line they are the
virgincare NHS Until recently, the prison did not facilitate annual training but have this year agreed to provide this and all colleagues will, therefore, complete an annual refresher. We attach as Appendix C a copy of the "Statutory and Mandatory refresherlupdate training [monthlyear]" from which it will be seen that 'ACCT self harm and suicide prevention training' will be carried out annually. To further embed the requirement for ACCT awareness, any new member of staff who has joined the Virgin Care healthcare team at HMP High Down will complete the induction process and thereafter there is requirement to_complete annual ACCL training_which forms part_of_the_appraisal_review process: At each appraisal, the training matrix is reviewed to ensure colleagues' training Is up to date. It is the responsibility of the Head of Healthcare and the Deputy Head of Healthcare to ensure that the matrix is updated as and when each member of staff completes the required training: Virgin Care is therefore confident that we now have in place a robust process for ensuring that colleagues have completed the appropriate ACCT awareness training and are aware of PSI 1700 when commence work at HMP High Down, and that they complete annual refresher training in these areas_ Virgin Care is also confident that the training scheme in place gives colleagues appropriate training regarding the ACCT process_ Although we are confident that in this case the Fitness for Segregation form was completed correctly_ we have also implemented an auditing_process to further assure ourselves of this (see Appendlx D): Our Lead Nurses within the prison Will now carry out four audits throughout each year ensuring that these_torms have been filled out adequately, that an appropriate entry is made on the clinical system (SystmOne) , an appropriate entry Ts made on the prisoner's history sheet and; where appropriate, an entry on the ACCT document is also made. material errors should therefore be picked up and; where appropriate, will be addressed at management supervision sessions, with additional training to ensure their competency_ In conclusion, Virgin Care welcomes the constructive comments made by the Coroner in his Regulation 28 Report. The contents of the report have been considered carefully , and Virgin Care has instituted changes to our procedures to ensure robust processes are in place to address the concerns raised by the Coroner_ Should the Coroner have any queries once he has had an opportunity to consider this letter and the attached documentation, he should not hesitate to contact us.
1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of accessors that mean prisoners go to segregation when should be in the health care wing, or that go without observation, when they should be on an ACCT and receive extra support" Virgin Care has been "asked to consider whether the process Is fit for purpose or whether redesign or further training is indicated" We respond as follows: Response The Coroner has recognised that the Nurse involved in this Inquest was not ACCT trained and unaware of PSI 1700. We accept the Coroner's recognition of events and can advise a8 follows. We attach as Appendix A a copy of the "Induction Checklist" for HMP High Down healthcare colleagues. This protocol sets out the induction programme which all healthcare colleagues are required to complete whilst are supernumerary_ This relates to a four week period where work supervised at all and so are not considered within staffing numbers for off purposes. Pages Virgin Care w; Www vireyinc?ue €.uk rRetgisIered diiicc; Virgi;: (Hals: Siruvi,es jnbnu tnt: 12Tavi;x %u:e_ 'xW' Wcihai)_ 5{jistxr(E i $.iex eis | PQ} W uae iJimnt04 0/80- Dale; 19/12/2016 v1.o RECEIVED clarify Party they they they they times duty
virgincar NHS one to three inclusive of the protocol set out a timetable for the expected timeframe for different areas of learning to be covered. The items on page three are expected to be completed within the first month of an individual commencing work at HMP High Down: Item 15 on page three of the induction checklist is "ACCT Awareness". This is current practice and was at the time of the death of Mr Walsh_ The induction process had been redrafted prior to the death but after had started and therefore the Nurse accurately reflected in his evidence that he had not received this ACCT training within his induction. HMP High Down prison colleagues are responsible for the formal training of all colleagues (including those in healthcare) in the ACCT Awareness process. During induction, an overview of the ACCT process is provided and colleagues are made clear the expectations of healthcare staff as of the ACC process. Within this training session, the importance of the ACCT process is conveyed and the attendance of Virgin Care colleagues attending the formal training provided by the prison is emphasised Following the induction ACCT awareness training, colleagues are required to sign to say they are satistied that they have received satisfactory ACCT awareness training; their line manager is also required to sign to say they are confident the new colleague is capable of applying their training and has understood_ In addition; on completion of their induction, arrangements are made for healthcare colleagues to sit in as an observer with experienced members of staff at an ACCT review meeting: This will ensure that new members of staff will not be required to take part_in an ACCL review untiL they_have_seen how the review meetings proceed Since the induction pack was introduced Algorithms" or alternatively "Fitness_for_Segregation" forms are also part of the Virgin Care Induction pack for healthcare colleagues at HMP High Down_ During induction these are scrutinised between staff and their Iine manager. At the conclusion of the training, the member of staff will sign, and thereby declare, that have received relevant training before their induction is completed and are able to work independently: As part of the_training; Virgin Care healthcare colleagues undergo scenario-based_training to allow them to practice completing and signing "Fitness for Segregation" forms_ An example of the form is attached at Appendix B_ Again; this is confirmed by the manager signing to say confident that the new colleague has understood and has demonstrated their competence during the scenario-based training: The Coroner considered at the Inquest that that the Fitness for Segregation form was not completed accurately by in the case of Richard Walsh: However, having reviewed the documentation as part of our response to the inquest, we consider that had completed this form correctly and the information he had at his disposal meant that this gentleman was fit for segregation: The patient was further reviewed by another nurse who also deemed him fit for segregation appears to have been led to doubt himself at the inquest. Since the Inquest, Virgin Care has arranged additional ACCT awareness training_with the HME High Down's_Safer Custody department to ensure all current healthcare colleagues receive training in next few weeks and this will be completed by the end of January 2017_ Once all colleagues have received initial or refresher training, this will be monitored on the colleague training log and relevant line managers will ensure all staff are given refresher training at least annually. Virgin Care WiWW Vinghcaxre,},lua Relji fareri aHiic;c; Vegin: (Gtia Sivicn; ~illoai |oixsn: 1XTavislrk: F quxhne? Vhxcim' Wi ime Kqsicnwvcl Exhulai%c} aiX Walxg; Naunizci 07255747/ Date: 19/12/2016 vi. part "Seg they they line they are the
virgincare NHS Until recently, the prison did not facilitate annual training but have this year agreed to provide this and all colleagues will, therefore, complete an annual refresher. We attach as Appendix C a copy of the "Statutory and Mandatory refresherlupdate training [monthlyear]" from which it will be seen that 'ACCT self harm and suicide prevention training' will be carried out annually. To further embed the requirement for ACCT awareness, any new member of staff who has joined the Virgin Care healthcare team at HMP High Down will complete the induction process and thereafter there is requirement to_complete annual ACCL training_which forms part_of_the_appraisal_review process: At each appraisal, the training matrix is reviewed to ensure colleagues' training Is up to date. It is the responsibility of the Head of Healthcare and the Deputy Head of Healthcare to ensure that the matrix is updated as and when each member of staff completes the required training: Virgin Care is therefore confident that we now have in place a robust process for ensuring that colleagues have completed the appropriate ACCT awareness training and are aware of PSI 1700 when commence work at HMP High Down, and that they complete annual refresher training in these areas_ Virgin Care is also confident that the training scheme in place gives colleagues appropriate training regarding the ACCT process_ Although we are confident that in this case the Fitness for Segregation form was completed correctly_ we have also implemented an auditing_process to further assure ourselves of this (see Appendlx D): Our Lead Nurses within the prison Will now carry out four audits throughout each year ensuring that these_torms have been filled out adequately, that an appropriate entry is made on the clinical system (SystmOne) , an appropriate entry Ts made on the prisoner's history sheet and; where appropriate, an entry on the ACCT document is also made. material errors should therefore be picked up and; where appropriate, will be addressed at management supervision sessions, with additional training to ensure their competency_ In conclusion, Virgin Care welcomes the constructive comments made by the Coroner in his Regulation 28 Report. The contents of the report have been considered carefully , and Virgin Care has instituted changes to our procedures to ensure robust processes are in place to address the concerns raised by the Coroner_ Should the Coroner have any queries once he has had an opportunity to consider this letter and the attached documentation, he should not hesitate to contact us.
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From Nicola Blackwood MP Parliamentary Under Secretary of State for Public Health and Innovation Department of Health Richmond House 79 Whitehall London SWIA 2NS Dr Andrew Harris HM Senior Coroner Inner London South 020 7210 4850 Southward Coroner s Court 1 Tennis Street 8 | 2017 London SE1 1TD ")er li> 10 January 2017 Thank you for your letter to Secretary of State about the death of Richard Walsh. am responding as the Minister with responsibility for mental health policy at the Department of Health (DH): was saddened to read of the circumstances surrounding Mr Walsh's death. Please pass my condolences to her family and loved ones. Mr Walsh committed suicide while an inmate at HMP Belmarsh: The Coroner has detailed Mr Walsh's experiences while detained the police station and two prisons, finding a number of failures. The inquest jury found that he would not have died had he been 'sectioned'_ note that your report has also been sent to Ministry of Justice, Home Office and local healthcare providers for response_ am writing regarding the concern specifically addressed to DH around Appropriate Mental Health Professional training) You wrote that the inadecuacv of the nurse assessment of fitness for segregation in HMP Highdown is a risk. was not ACCT trained and it appeared that he was unaware of PSI 1700_ The inadequacy may reflect individual of wider weakness in assessment or choice of assessors that mean that prisoners go to segregation when should be in the health care wing; or that go without observation; when should be on an ACCT and receive extra support: You asked that the inquest findings be brought to the attention of those who lead the 'Departmental training programme' for Approved Mental Healthcare Practitioners (AMHPs) and consideration be given as to Whether further guidance or training regarding Mental Health Act Assessments is required: Responsibility for approving and monitoring AMHP programmes offered by Higher Education Institutions in England (HEIs) is held by the Health and Care Professions Council (HCPC): The HCPC is an independent; UK-wide regulatory body which has responsibility for approving and monitoring AMHP programmes offered by HEIs in England. They have RECEIVED JAN they they they
published criteria, that set out its expectations of educational providers and individuals completing these programmes: To explain, to be approved to act as an Approved Mental Health Professional by a local social services authority, AMHPs must have undertaken an accredited training course provided at a higher education institution and on completion of that course; be able to demonstrate competence to practise in the role. Schedule 2 of the Mental Health (Approved Mental Health Professionals) (Approval) (England) Regulations 2008 sets out the competences of an AMHP required by law. There is a statutory requirement that the AMHP is approved each year: To achieve this, the AMHP must complete at least 18 hours of training agreed with the approving Social Services Authority as being relevant to their role as an AMHP as stated in the Regulations [5(a)]: The criteria for approving AMHP programmes are designed to equip individuals with the threshold skills necessary to engage in safe and effective practice_ set out the processes and procedures that education providers delivering AMHP training must have in place, and the knowledge, understanding and skills that an individual must have when complete their AMHP training, including the necessary knowledge and skills to undertake formal Mental Health Act Assessments_ As requested, have brought your report to the attention of the HCPC and asked them to respond to you directly: that this information is useful. Thank you for bringing the circumstances of Mr Walsh's death to our attention: Yus Nab_ NICOLA BLACKWOOD They they hope Sinul7
published criteria, that set out its expectations of educational providers and individuals completing these programmes: To explain, to be approved to act as an Approved Mental Health Professional by a local social services authority, AMHPs must have undertaken an accredited training course provided at a higher education institution and on completion of that course; be able to demonstrate competence to practise in the role. Schedule 2 of the Mental Health (Approved Mental Health Professionals) (Approval) (England) Regulations 2008 sets out the competences of an AMHP required by law. There is a statutory requirement that the AMHP is approved each year: To achieve this, the AMHP must complete at least 18 hours of training agreed with the approving Social Services Authority as being relevant to their role as an AMHP as stated in the Regulations [5(a)]: The criteria for approving AMHP programmes are designed to equip individuals with the threshold skills necessary to engage in safe and effective practice_ set out the processes and procedures that education providers delivering AMHP training must have in place, and the knowledge, understanding and skills that an individual must have when complete their AMHP training, including the necessary knowledge and skills to undertake formal Mental Health Act Assessments_ As requested, have brought your report to the attention of the HCPC and asked them to respond to you directly: that this information is useful. Thank you for bringing the circumstances of Mr Walsh's death to our attention: Yus Nab_ NICOLA BLACKWOOD They they hope Sinul7
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Park House tel +44 (0J300 500 6184 health & care 184 Konnington Park Road fax +44 (0J20 7820 9684 hcpc professions London SE11 4BU wwwhcpc-ukorg council Dr Andrew Harris Chief Executive and Registrar: Marc Seale Senior Coroner for Inner South District Greater London Southwark Coroner's Court 1 Tennis Street London, SE1 1YD 13 February 2017 tl_s PFD (Prevent Future Deaths) report touching the death of Richard Walsh Date of death: 19/07/2015 am writing in connection with the above report. Nicola Blackwood MP wrote to me in January 2017 in connection with your request that the findings of your report be brought to the attention of those who lead the 'Departmental training programme' for Approved Mental Health Practitioners (AMHPs): We understand that Ms Blackwood advised you that she had brought this matter to our attention We have given careful consideration to the findings of your report We have a statutory responsibility to set criteria for initial Approved Mental Health Professional (AMHP) training and to approve training programmes: Having reviewed the criteria that we first published in 2013, we are confident that they continue to set out appropriate requirements for qualifying training, including requirements for those_ completing training to have acquired necessary skills in carrying out mental health assessments_ However as we only assumed responsibility for approving AMHP training in 2012, we are cognisant that the nurse involved in this case may well have undertaken training assessed against different requirements_ am also mindful that our responsibility for AMHP training is due to become the responsibility of a new regulator; Social Work England, in 2018. We will ensure that the new regulator is aware of this report and our correspondence Successful completion of an approved programme only makes an individual eligible to be approved to as an AMHP Under The Mental Health (Approved Mental Health Professionals) (Approval) (England) (England) Regulations 2008 approval to act a8 an AMHP rests with a Local Social Services Authority (LSSA) in England: The LSSA also has responsibility under the regulations for ensuring that the AMHPs approve receive at least 18 hours of training per year relevant to their role. This is likely to be most effective means of addressing the specific RECEIVE 46FE act they the
issues that you raise in your report: have copied this letter to Nicole Blackwood MP to suggest that bringing your report to the attention of LSSA's in the context of their ongoing training obligations might be an effective way of drawing attention to issues that you raise hope this letter is helpful. Please do contact me if we can assist in any way in the future_ l Marc Seale Chief Executive and Registrar CC. Nicola Blackwood the MP
issues that you raise in your report: have copied this letter to Nicole Blackwood MP to suggest that bringing your report to the attention of LSSA's in the context of their ongoing training obligations might be an effective way of drawing attention to issues that you raise hope this letter is helpful. Please do contact me if we can assist in any way in the future_ l Marc Seale Chief Executive and Registrar CC. Nicola Blackwood the MP
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1 Hampshire County Council & Portsmouth City Council Response to the PFD (Prevent Future Deaths) Coroners report touching the death of Richard Walsh Date of Death: 19/07/2015 Case Number:-01936-2015
1.0 Introduction
1.1 This response is being provided on behalf of Hampshire County Council (HCC) as the responsible Local Authority which employed the Approved Mental Health Professional (AMHP) involved in the Mental Health Act assessment of Mr Richard Walsh conducted on the 27th June 2016. This response is also being supported by Portsmouth City Council (PCC) as the current employer of in his role as AMHP and as a key agency involved in the local health and social care system in Hampshire.
1.2 HCC and PCC share an equal commitment to address the serious concerns raised by the Coroner and the findings of the Inquest Jury in relation to the tragic death of Mr Richard Walsh. Having reviewed the PFD report, HCC and PCC have considered the role of the local authority in the circumstances of their statutory responsibilities for providing an AMHP to carry out an assessment under s13 Mental Health Act 1983 with specific reference to persons in Police Custody.
1.3 This response is structured in light of the review of the PFD report which references specific concerns regarding AMHP practice, Information Management, the standard of MHA assessments (in Police Custody), training and development of AMHPs, professional registration of and the wider systemic learning both locally and nationally, stemming from this incident.
2.0 AMHP Professional Practice
2.1 Communication with Relatives & ‘Nearest Relatives’ as defined under s26 Mental Health Act 1983 In light of evidence made available at the Inquest, a matter of concern has been raised in the PFD report regarding communication between those conducting the assessment and the patient’s relatives. The Mental Health Act (s26) is prescriptive about the identification and statutory role of the Nearest Relative of the patient as a means of providing a safeguard within the Mental Health Act assessment process. The AMHP role in turn, is governed by a set of duties under Statute to ensure that the Nearest Relative is properly consulted and included in the process as required. Duties toward the role of ‘relatives’ is informed by s13(1A) (b) requiring the AMHP have regard ‘to any wishes expressed by relatives
2 of the patient’. Best practice is also informed by principles of the Mental Health Act Code of Practice for the AMHP role. Due to the findings of the Inquest concerning the assessment conducted with Mr Walsh, HCC/ PCC will be developing AMHP practice guidance to support decision making for when a relative needs to be consulted about someone presenting in the Police Custody environment. Such AMHP guidance will highlight the necessity for such consultation on the grounds of the gravity of the presenting facts, the nature of the offence, the history of the individual, the availability and suitability of the relative, the views of the person subject to assessment and other relevant criteria.
2.2 Examination of the Custody Log and/or police station records The Coroner has highlighted the fact that the MHA assessors did not directly examine the custody record or log. HCC/ PCC fully support the requirement that AMHPs need to directly scrutinise the Police Custody record and not rely solely on verbal feedback from Police staff. HCC/ PCC will be publishing guidance to AMHP staff referencing this requirement.
2.3 Consultation and consideration of the ‘patient’ medical forms The Coroner has highlighted the fact that the MHA assessors did not directly examine the ‘Detained Persons Medical Forms’. HCC/ PCC fully support the requirement that AMHPs need to directly scrutinise the ‘Detained Persons Medical Forms’ and not rely solely on verbal feedback from Police staff. HCC/ PCC will be publishing guidance to AMHP staff referencing this practice requirement.
2.4 Accessing information from Police Custody Officers The Coroner has highlighted that the Custody Officers and the MHA assessors never spoke. HCC/ PCC concur that the AMHP needs to speak directly with the Police Custody Officer as a priority when carrying out each assessment in a Police Custody Centre. HCC/ PCC will publish guidance to AMHP staff referencing this requirement following further liaison with Hampshire Constabulary.
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3.0 Management of information related to the MHA assessment process
3.1 Sharing AMHP reports with Prison healthcare and/ or GP practice The Coroner report has highlighted the need for a national process for information sharing in view of the role, in this case, of general practice and/ or prison healthcare. Local services across Hampshire record information about people using services on a variety of different systems regulated by Information Governance policies. HCC/ PCC would concur that the sharing of such sensitive information will be necessary in the specific ongoing provision of care and support of vulnerable persons involved in the criminal justice system. HCC/ PCC will provide a clear set of practice guidance to ensure that AMHPs are able to provide relevant information ‘in confidence’ to GP practice/ prison healthcare regarding people who have been subject to MHA assessment in Police Custody.
3.2 Sharing AMHP reports with Police The Coroner report raised concern where there was no report or letter or appropriate communication about the MHA assessment completed in the Police Station to subsequent health care providers. The Coroner further stated concern in regard to the availability of relevant information for the purposes of the Prisoner Escort Record (PER). HCC/ PCC will be working with local NHS Provider Trusts and Hampshire Constabulary to review information sharing with the Police following joint assessment in Police Custody. In November 2016 HCC/ PCC have introduced a requirement for AMHPs to receive a written medical report from the assessing Doctors in circumstances where their assessment has not led to the provision of medical recommendations supporting application for detention under Part 2 Mental Health Act 1983. The completion of this report will evidence the rationale for clinical decision making and corresponding AMHP decision making (see Appendix One).
4.0 Maintaining and improving standards of MHA assessments by practitioners in Police Custody The standard of mental health act assessments is brought into question by the Coroner in light of the findings from this inquest. Certainly the conduct of each of the practitioners involved in this case is referred to separately. HCC/ PCC recognise that a robust governance framework is required to provide greater assurance and transparency to the public whereby decisions are taken by AMHPs when assessing persons under the Mental Health Act whilst in Police Custody. Such a framework will include the monitoring of MHA outcomes for persons arrested for an offence in need of a MHA assessment, information sharing –
4
both to inform decision making and outcomes for the benefit of other agencies, communication with relatives/ carers, AMHP training records specific to assessments for people arrested for an offence.
5.0 Training and Professional Development for AMHP staff when dealing with assessments in Police Custody
The Coroner has raised concern about the availability and provision of AMHP training on MHA assessments in police stations.
In light of the findings of this inquest, HCC/ PCC will be reviewing the current professional development opportunities for AMHP staff in order to ensure the standard of practice when assessing persons in Police Custody is consistent and in line with best practice.
The findings of this report will also be shared with AMHP training providers, the Health and Social Care Professionals Council (HCPC) and other relevant professional training bodies to ensure that AMHP training and refresher training includes the learning from this report.
6.0 Professional Regulatory review of
Following the tragic circumstances of this event, and Portsmouth City Council as his employer, can confirm that his professional practice as a registered social worker was referred to the Health and Care Professionals Council (HCPC) on the 03/10/2016.
HCPC requested information connected to the case and Portsmouth City Council has provided them with the following documents:
1. The Jury's Narrative Verdict
2. The Coroner's Report
3. The Prisons and Probation Ombudsman's report into the death of RW
4. The independent social work report commissioned by Hampshire County Council written by and dated the 16th of September.
5. A report from a senior manager at Portsmouth City Council regarding current practice.
HCPC have reviewed these documents and have decided that they will not be holding a fitness to practice hearing. They will be taking no further action and the case will be closed.
In addition to the above, was randomly selected by HCPC, as part of the re-registration process to provide evidence of his continuous professional development. has provided a portfolio of evidence and this resulted in his re- registration being confirmed.
5
PCC have audited assessments to ensure they are of a good standard. This practice is undertaken routinely within the Portsmouth AMHP service and will continue for all AMHPs. The manager of the service has been satisfied that work is of a high standard.
7.0 Systemic learning
The PFD report highlights the range of organisations involved in the experience of Mr Walsh and his family through the course of his dealings with the criminal justice system.
HCC/ PCC will be seeking to work alongside the relevant agencies in respect to their key responsibilities under the Mental Health Act 1983, specifically in relation to their duties to make arrangements for providing an AMHP to consider a ‘patients’ case.
HCC/ PCC will be seeking to share the learning from this case with relevant agencies to improve practice of the AMHP when assessing persons in police custody.
8.0 Summary
The inquest into the death of Mr Richard Walsh has highlighted the very sad circumstances which led to his death by suicide on 19th July 2015. The Coroner has raised a number of concerns about the role of the AMHP and both psychiatrists in this case citing Neglect on four counts.
HCC and PCC are committed to learn from this tragic experience in light of the findings of the Coroner.
Head of Mental Health and Substance Misuse Signature:-
1.0 Introduction
1.1 This response is being provided on behalf of Hampshire County Council (HCC) as the responsible Local Authority which employed the Approved Mental Health Professional (AMHP) involved in the Mental Health Act assessment of Mr Richard Walsh conducted on the 27th June 2016. This response is also being supported by Portsmouth City Council (PCC) as the current employer of in his role as AMHP and as a key agency involved in the local health and social care system in Hampshire.
1.2 HCC and PCC share an equal commitment to address the serious concerns raised by the Coroner and the findings of the Inquest Jury in relation to the tragic death of Mr Richard Walsh. Having reviewed the PFD report, HCC and PCC have considered the role of the local authority in the circumstances of their statutory responsibilities for providing an AMHP to carry out an assessment under s13 Mental Health Act 1983 with specific reference to persons in Police Custody.
1.3 This response is structured in light of the review of the PFD report which references specific concerns regarding AMHP practice, Information Management, the standard of MHA assessments (in Police Custody), training and development of AMHPs, professional registration of and the wider systemic learning both locally and nationally, stemming from this incident.
2.0 AMHP Professional Practice
2.1 Communication with Relatives & ‘Nearest Relatives’ as defined under s26 Mental Health Act 1983 In light of evidence made available at the Inquest, a matter of concern has been raised in the PFD report regarding communication between those conducting the assessment and the patient’s relatives. The Mental Health Act (s26) is prescriptive about the identification and statutory role of the Nearest Relative of the patient as a means of providing a safeguard within the Mental Health Act assessment process. The AMHP role in turn, is governed by a set of duties under Statute to ensure that the Nearest Relative is properly consulted and included in the process as required. Duties toward the role of ‘relatives’ is informed by s13(1A) (b) requiring the AMHP have regard ‘to any wishes expressed by relatives
2 of the patient’. Best practice is also informed by principles of the Mental Health Act Code of Practice for the AMHP role. Due to the findings of the Inquest concerning the assessment conducted with Mr Walsh, HCC/ PCC will be developing AMHP practice guidance to support decision making for when a relative needs to be consulted about someone presenting in the Police Custody environment. Such AMHP guidance will highlight the necessity for such consultation on the grounds of the gravity of the presenting facts, the nature of the offence, the history of the individual, the availability and suitability of the relative, the views of the person subject to assessment and other relevant criteria.
2.2 Examination of the Custody Log and/or police station records The Coroner has highlighted the fact that the MHA assessors did not directly examine the custody record or log. HCC/ PCC fully support the requirement that AMHPs need to directly scrutinise the Police Custody record and not rely solely on verbal feedback from Police staff. HCC/ PCC will be publishing guidance to AMHP staff referencing this requirement.
2.3 Consultation and consideration of the ‘patient’ medical forms The Coroner has highlighted the fact that the MHA assessors did not directly examine the ‘Detained Persons Medical Forms’. HCC/ PCC fully support the requirement that AMHPs need to directly scrutinise the ‘Detained Persons Medical Forms’ and not rely solely on verbal feedback from Police staff. HCC/ PCC will be publishing guidance to AMHP staff referencing this practice requirement.
2.4 Accessing information from Police Custody Officers The Coroner has highlighted that the Custody Officers and the MHA assessors never spoke. HCC/ PCC concur that the AMHP needs to speak directly with the Police Custody Officer as a priority when carrying out each assessment in a Police Custody Centre. HCC/ PCC will publish guidance to AMHP staff referencing this requirement following further liaison with Hampshire Constabulary.
3
3.0 Management of information related to the MHA assessment process
3.1 Sharing AMHP reports with Prison healthcare and/ or GP practice The Coroner report has highlighted the need for a national process for information sharing in view of the role, in this case, of general practice and/ or prison healthcare. Local services across Hampshire record information about people using services on a variety of different systems regulated by Information Governance policies. HCC/ PCC would concur that the sharing of such sensitive information will be necessary in the specific ongoing provision of care and support of vulnerable persons involved in the criminal justice system. HCC/ PCC will provide a clear set of practice guidance to ensure that AMHPs are able to provide relevant information ‘in confidence’ to GP practice/ prison healthcare regarding people who have been subject to MHA assessment in Police Custody.
3.2 Sharing AMHP reports with Police The Coroner report raised concern where there was no report or letter or appropriate communication about the MHA assessment completed in the Police Station to subsequent health care providers. The Coroner further stated concern in regard to the availability of relevant information for the purposes of the Prisoner Escort Record (PER). HCC/ PCC will be working with local NHS Provider Trusts and Hampshire Constabulary to review information sharing with the Police following joint assessment in Police Custody. In November 2016 HCC/ PCC have introduced a requirement for AMHPs to receive a written medical report from the assessing Doctors in circumstances where their assessment has not led to the provision of medical recommendations supporting application for detention under Part 2 Mental Health Act 1983. The completion of this report will evidence the rationale for clinical decision making and corresponding AMHP decision making (see Appendix One).
4.0 Maintaining and improving standards of MHA assessments by practitioners in Police Custody The standard of mental health act assessments is brought into question by the Coroner in light of the findings from this inquest. Certainly the conduct of each of the practitioners involved in this case is referred to separately. HCC/ PCC recognise that a robust governance framework is required to provide greater assurance and transparency to the public whereby decisions are taken by AMHPs when assessing persons under the Mental Health Act whilst in Police Custody. Such a framework will include the monitoring of MHA outcomes for persons arrested for an offence in need of a MHA assessment, information sharing –
4
both to inform decision making and outcomes for the benefit of other agencies, communication with relatives/ carers, AMHP training records specific to assessments for people arrested for an offence.
5.0 Training and Professional Development for AMHP staff when dealing with assessments in Police Custody
The Coroner has raised concern about the availability and provision of AMHP training on MHA assessments in police stations.
In light of the findings of this inquest, HCC/ PCC will be reviewing the current professional development opportunities for AMHP staff in order to ensure the standard of practice when assessing persons in Police Custody is consistent and in line with best practice.
The findings of this report will also be shared with AMHP training providers, the Health and Social Care Professionals Council (HCPC) and other relevant professional training bodies to ensure that AMHP training and refresher training includes the learning from this report.
6.0 Professional Regulatory review of
Following the tragic circumstances of this event, and Portsmouth City Council as his employer, can confirm that his professional practice as a registered social worker was referred to the Health and Care Professionals Council (HCPC) on the 03/10/2016.
HCPC requested information connected to the case and Portsmouth City Council has provided them with the following documents:
1. The Jury's Narrative Verdict
2. The Coroner's Report
3. The Prisons and Probation Ombudsman's report into the death of RW
4. The independent social work report commissioned by Hampshire County Council written by and dated the 16th of September.
5. A report from a senior manager at Portsmouth City Council regarding current practice.
HCPC have reviewed these documents and have decided that they will not be holding a fitness to practice hearing. They will be taking no further action and the case will be closed.
In addition to the above, was randomly selected by HCPC, as part of the re-registration process to provide evidence of his continuous professional development. has provided a portfolio of evidence and this resulted in his re- registration being confirmed.
5
PCC have audited assessments to ensure they are of a good standard. This practice is undertaken routinely within the Portsmouth AMHP service and will continue for all AMHPs. The manager of the service has been satisfied that work is of a high standard.
7.0 Systemic learning
The PFD report highlights the range of organisations involved in the experience of Mr Walsh and his family through the course of his dealings with the criminal justice system.
HCC/ PCC will be seeking to work alongside the relevant agencies in respect to their key responsibilities under the Mental Health Act 1983, specifically in relation to their duties to make arrangements for providing an AMHP to consider a ‘patients’ case.
HCC/ PCC will be seeking to share the learning from this case with relevant agencies to improve practice of the AMHP when assessing persons in police custody.
8.0 Summary
The inquest into the death of Mr Richard Walsh has highlighted the very sad circumstances which led to his death by suicide on 19th July 2015. The Coroner has raised a number of concerns about the role of the AMHP and both psychiatrists in this case citing Neglect on four counts.
HCC and PCC are committed to learn from this tragic experience in light of the findings of the Coroner.
Head of Mental Health and Substance Misuse Signature:-
Action Should Be Taken
In my opinion action should be taken to prevent future deaths: I believe that the following organizations or individuals have the power to take such action 1, The Secretaries of State of Home Office, Health and Ministry of Justice are notified of Matter no.1, the apparent defects in the system of communication. are asked to consider not only the adequacy of the instant organization'$ response, but whether there is a need to consider the risks are more appropriately addressed nationally:
2. In view of the conclusion of the jury with regard to neglect; the following are notified of Matter no. 2 about the adequacy and safety of MHA assessments_ are asked to consider whether they should refer themselves to their professional body, as their colleague b) The Department of Health is also asked to draw to the attention of those leading the Departmental Training programme for AMHPs the circumstances and findings of this inquest and consider whether further guidance or training with regard to the performance of Mental Health Act Assessments is required. 3 . Virgin Health Care is notified of Matter no. 3,the weaknesses and lack of training admitted by their nurse in conducting the fitness for segregation assessment and asked to consider whether the process is fit for purpose or whether redesign or further training is indicated.
2. In view of the conclusion of the jury with regard to neglect; the following are notified of Matter no. 2 about the adequacy and safety of MHA assessments_ are asked to consider whether they should refer themselves to their professional body, as their colleague b) The Department of Health is also asked to draw to the attention of those leading the Departmental Training programme for AMHPs the circumstances and findings of this inquest and consider whether further guidance or training with regard to the performance of Mental Health Act Assessments is required. 3 . Virgin Health Care is notified of Matter no. 3,the weaknesses and lack of training admitted by their nurse in conducting the fitness for segregation assessment and asked to consider whether the process is fit for purpose or whether redesign or further training is indicated.
Report Sections
Investigation and Inquest
On 22nd July 2015,1 commenced an investigation and on 24th July [ opened an inquest into the death of Richard Walsh, who died on 19th July 2015 in HMP Belmarsh, Western Way, Thamesmead, London; Case Ref: 01936 -15 (JB). It was concluded on 27th September 2016. The jury concluded in a narrative conclusion that he came by his death by suicide. returned a finding that omissions in a Mental Health Act Assessment after his arrest and detention in a police station, before transfer to prison, amounted to Neglect on four counts: Failure of both psychiatrists and of the Approved Mental Health Act Practitioner to seek clinical information, Failure to admit to hospital under MHA section, and Failure to conduct an adequate Mental Health Act Assessment: The jury concluded that he would not have died when he did if he had been 'sectioned". CIRCUMSTANCES OF THE DEATH An expert psychiatrist gave evidence, having considered his behaviour of unprovoked stabbing of 2 his delusions, hiding under a blanket in the police station, his obsession with a police woman, his outburst in prison, and study of a previous admission under mental health care that he suffered from De Clerambault syndrome (erotomania) and was suffering psychosis After arrest and They boys, charged with attempted murder; the deceased had delusions and refused to drink or eat for 48 hours with a stated intention to police officers that he would thus die on the 3rd He was remanded to HMP Highdown, where he was segregated; transferred to HMP Belmarsh 3 later; where he was isolated in a single cell, for his protection, for 23 !z hours a where he himself after 17 days. CORONER'S CONCERNS During the course of the inquest; the evidence revealed a matter giving rise to concern that in my opinion means that there is still a risk that future deaths occur unless action is taken. In the circumstances it is my statutory to report to you: The MATTERS OF CONCERN are as follows.
1. The expert psychiatrist gave an opinion that there was a defect in the system of communications between professionals and agencies involved in the care of Mr Walsh: There appeared to be not only serious failures of communication, but failurcs inadequate processes of communication between custodial and health professionals, between police, court; health care and prison services, that progressively crucial information about the risks and needs of the deceased as he passed through different hands. The expert described what staff knew at HMP Belmarsh as diluted and grossly distorted. Evidence heard is listed: Those conducting the MHA assessment did not discover that; on the very evening of the assessment; the police had been in contact with the deceased mother, who had information about his mental health, nor did examine the custody record or nor consult the Detained Persons Medical Forms, which one described as usually containing little useful information. The Custody officers and MHA assessors never spoke.
6) The AMHP said that the Mental Health Act (MHA) assessment was put on RIO system for Hampshire NHS staff; and could be made available to general practice Or healthcare on request; but was not automatically transferred. There was a need for a national process of information sharing: c) The Custody Advisor informs the court that the national system was that the Detained Person's Medical Forms (DPMFs) were routinely scanned onto the police RMS system, but the Mental Health Act Assessment is not: The logic was not apparent; as both would appear to have the same quality of confidence. Medical in confidence information police stations was sometimes transmitted in sealed envelopes marked Confidential, travelling with the prisoner, but the independent psychiatric expert thought that this was the least effective form of communication and recommended that the assessing team should communicate with the next stage in the process, such as contacting the catchment area forensic service by phone out of advising that the prisoner is likely to go to a particular court; and writing a letter with the assessment in office hours. The Police Custody Advisor said that he would not expect the Mental Health Act day: days hung day, will duty from lost key log, prison from hours,
Assessment report to routinely go to the court or prisons with the Prisoner Escort Record (PER), unless the prisoner was sectioned. The logic for this was also not clear; as the non sectioned patient was more at risk of not having appropriate mental health care non communication, than the sectioned one. e) No report or letter or appropriate communication about the MHA assessment was completed in the police station to subsequent health care providers, nor was there a system to require it: f) There was no evidence that the police doctor (FME) and police nurses notes, called Detained Person's Medical Forms (DPMFs) were ever seen by anyone with responsibility for Mr Walsh in Highdown or Belmarsh prisons, nor evidence of any established process of transfer of the information: Prison staff said that medical in confidence information can be scanned to prison health care, but there was not an established system of 'securing medical records from police stations. The Pre-Release risk assessment was completed by a custody officer, indicating that the deceased had no risks. The Custody Advisor indicated that the officer did not appear to understand the system, as this particular questionnaire in the custody record should not have been completed for transfer to court: But it appeared that its negative entries may have misled others assessing risk at time of transfer h) The completion of the PER in the police station did not reflect the contents of the custody record or custody failing to record his attempt to commit suicide by dehydration, his delusions, his obsession, or that he had been assessed as high risk of suicide. The Custody Advisor said that the system was meant to be that the PER was signed off by the custody officer; who should have known that the information was incorrect: i) The police staff completing the PER indicated she routinely did this without consultation with the custody log Or custody record, which was not required, although the Custody Advisor informed the court that this was not meant to be the system. j) The care plan at the police station which was recorded in detail in the custody record (and is meant to record any risks and evidence of mental illness) was not sent onwards with the PER, nor was the section on the PER marked Care Plan completed, as the Custody Advisor informed it should be. Staff informed the court it never is. k) Staff at the first night centre assessment at HMP Highdown saw the basic information about his offence and recent history and the police national computer printout with no markers, although a subsequent one was found with markers, indicating a previous attempt in custody to himself in custody and a threat to stab anyone who takes his children. There was no cxplanation for a false negative sent: from 1og, - hang being
1) It is not clear if the nurse the health screen at HMP Highdown was shown or looked at the PER from the police station: m) It is not clear whether the nurse assessing health fitness for segregation in HMP Highdown by completing a proforma, did consult the System One Medical Records, but the nurse that he had no information on the prisoner'$ behaviour and health in the police station, nor over the preceding four weeks, which he needed, and that he expected the reception nurse to information to him and it was not for him to go to Reception to get it: n) The PER completed at HMP Highdown did not even reflect the limited information had received from the police station three earlier. It recorded no current health risks although the previous PER from the police station had indicated non compliance with MHA assessment and depression, a GP letter received reported a previous overdose in February and the decision had been made in reception that he needed mental health in reach service: The health care officer just recorded "fit for transfer"
0) The prison officer conducting the first night centre assessment in HMP Belmarsh did not see or consider the PER from police station to HMP Highdown, three previously: He did know he had a serious charge coming Up for sentence and had no family support and was going to be isolated for 23 Vz hours a in a single cell. He did not know he was depressed and on antidepressants, and if he had he would have opened an ACTT: Yet this information was known to health care staff: He reports that the nurse told him of no concerns and he told her of none: p) It was not apparent that the first night nurse assessment in HMP Belmarsh knew of or included consideration of his status on a care regime' which isolated him for his protection from other inmates. The nurse did not feel there was time nor was it his to review the medical records. He completed his proforma recording what the prisoner replied, even though he had information that it may be untrue and did not regard it was his to record or reconcile differences. The reception GP assessment in HMP Belmarsh did not consider his status isolated on a care regime although it was risk factor; nor had any knowledge of his behaviour in the police station or see any relevant information PNomis or discipline staff.
1) The GP the GP assessment in HMP Belmarsh informed the court that there was insufficient time in his to revicw the inmate medical records. He that the records showed that suicide six risk factors listed in Early Days in Custody were present recent change in circumstance, transfer another establishment; violent offence,history self harm and suicide,potentially category doing agreed bring days they days day 'duty job job agreed duty from doing job agreed
Aand history of mental illness and O1 alcohol problems. He had neither been informed of these factors nor identified them from the records and s0 neither opened an ACCT nor referred him to a psychiatrist: He was referred to the MH in-reach team by the nurse. That team reviewed his medical records, showing a history of alcohol abuse and depression on treatment (which did not apparently include any from the police station, which the psychiatrist said he does not routinely see) and were reassured by his not being followed up by a psychiatrist in the community after previous psychiatric admission, and by his presentation not raising any concerns for almost all the doctors and nurses, who had seen him in prisons. did not see any PERs, and was not informed he was isolated in a of care regime for 23 Vz hours a nor that the victims were children. The decision not to conduct a psychiatric assessment would have been different if he had scen the PERs or DPMFs or MHA assessment; or his in patient psychiatric notes The independent psychiatrist gave an opinion that the loss of information was a particular concern as people move in and out of custody so that there was a potential that information would be lost to the civilian GP. Whilst some organizations had taken a number of stcps to minimize the risks to the lives of others, particular the development of a national PER, others had only awoken to the risks in the closing days of the inquest: Virgin Health Care chose not to attend; Southern Health and Oxleas NHS Trust submitted plans to prevent future deaths before the inquest concluded. Hampshire Constabulary reported changes in training and staff awareness. Hampshire County Council prepared a short document of proposed actions, but it was not available as evidence as it was received by the court after the conclusion of the evidence: The evidence taken as a whole, suggested that there was a breakdown of communication at every professional and organizational interface, 18 of which are illustrated above. There was n0 system for transfer of health care information from police station court; or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or it if it was not in possession, whether there was also one to ask for it and if s0 which individual bore that responsibility: There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system; by rote with either no time to consider the whole person, O1 no sense that it was their responsibility to consider missing or discordant information Or to be proactive in communicating gaps in knowledge Or concerns. From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened.
2. That the standard of Mental Health Act assessments by these individuals needs to be improved, and, given all three were in agreement; that also training and provision for MHA assessments in police stations more widely may need to be reviewed_ drug They 'duty being day, key agreed complete
3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment o choice of assessors that mean that prisoners go to segregation when should be in the health care wing, or that go without observation, when they should be onan ACCT and receive extra support: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths: I believe that the following organizations or individuals have the power to take such action 1, The Secretaries of State of Home Office, Health and Ministry of Justice are notified of Matter no.1, the apparent defects in the system of communication. are asked to consider not only the adequacy of the instant organization'$ response, but whether there is a need to consider the risks are more appropriately addressed nationally:
2. In view of the conclusion of the jury with regard to neglect; the following are notified of Matter no. 2 about the adequacy and safety of MHA assessments_ are asked to consider whether they should refer themselves to their professional body, as their colleague b) The Department of Health is also asked to draw to the attention of those leading the Departmental Training programme for AMHPs the circumstances and findings of this inquest and consider whether further guidance or training with regard to the performance of Mental Health Act Assessments is required. 3 . Virgin Health Care is notified of Matter no. 3,the weaknesses and lack of training admitted by their nurse in conducting the fitness for segregation assessment and asked to consider whether the process is fit for purpose or whether redesign or further training is indicated. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by Tuesday December 20*h 2016. [, 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: If you require any further information Or assistance about the case, please contact the case officer, they they They has days
COPIES and PUBLICATION [have sent a copy of my report to the following Interested Persons: of Hickman and Rose Solicitors for the family, Government Legal for HMP Belmarsh, Capsticks Solicitors for Oxleas, Thompsons Solicitors for Prison Officers Association] Virgin Health Care, Hampshire PoliceDAC Beachcroft for and Stephen Fidler Solicitors for] Medical Protection Society: Ihave also sent it to The Royal College of Psychiatrists and independent psychiatric expert; who may find it useful or of interest: The court is to provide further documentation to the or t0 Ministers, if it would assist in their deliberations. Lam also under a to send a copy to the Chief Coroner as well as a copy of your response: 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 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: [DATE] [SIGNED BY CORONER] 2S (0 - (6 happy College duty may
1. The expert psychiatrist gave an opinion that there was a defect in the system of communications between professionals and agencies involved in the care of Mr Walsh: There appeared to be not only serious failures of communication, but failurcs inadequate processes of communication between custodial and health professionals, between police, court; health care and prison services, that progressively crucial information about the risks and needs of the deceased as he passed through different hands. The expert described what staff knew at HMP Belmarsh as diluted and grossly distorted. Evidence heard is listed: Those conducting the MHA assessment did not discover that; on the very evening of the assessment; the police had been in contact with the deceased mother, who had information about his mental health, nor did examine the custody record or nor consult the Detained Persons Medical Forms, which one described as usually containing little useful information. The Custody officers and MHA assessors never spoke.
6) The AMHP said that the Mental Health Act (MHA) assessment was put on RIO system for Hampshire NHS staff; and could be made available to general practice Or healthcare on request; but was not automatically transferred. There was a need for a national process of information sharing: c) The Custody Advisor informs the court that the national system was that the Detained Person's Medical Forms (DPMFs) were routinely scanned onto the police RMS system, but the Mental Health Act Assessment is not: The logic was not apparent; as both would appear to have the same quality of confidence. Medical in confidence information police stations was sometimes transmitted in sealed envelopes marked Confidential, travelling with the prisoner, but the independent psychiatric expert thought that this was the least effective form of communication and recommended that the assessing team should communicate with the next stage in the process, such as contacting the catchment area forensic service by phone out of advising that the prisoner is likely to go to a particular court; and writing a letter with the assessment in office hours. The Police Custody Advisor said that he would not expect the Mental Health Act day: days hung day, will duty from lost key log, prison from hours,
Assessment report to routinely go to the court or prisons with the Prisoner Escort Record (PER), unless the prisoner was sectioned. The logic for this was also not clear; as the non sectioned patient was more at risk of not having appropriate mental health care non communication, than the sectioned one. e) No report or letter or appropriate communication about the MHA assessment was completed in the police station to subsequent health care providers, nor was there a system to require it: f) There was no evidence that the police doctor (FME) and police nurses notes, called Detained Person's Medical Forms (DPMFs) were ever seen by anyone with responsibility for Mr Walsh in Highdown or Belmarsh prisons, nor evidence of any established process of transfer of the information: Prison staff said that medical in confidence information can be scanned to prison health care, but there was not an established system of 'securing medical records from police stations. The Pre-Release risk assessment was completed by a custody officer, indicating that the deceased had no risks. The Custody Advisor indicated that the officer did not appear to understand the system, as this particular questionnaire in the custody record should not have been completed for transfer to court: But it appeared that its negative entries may have misled others assessing risk at time of transfer h) The completion of the PER in the police station did not reflect the contents of the custody record or custody failing to record his attempt to commit suicide by dehydration, his delusions, his obsession, or that he had been assessed as high risk of suicide. The Custody Advisor said that the system was meant to be that the PER was signed off by the custody officer; who should have known that the information was incorrect: i) The police staff completing the PER indicated she routinely did this without consultation with the custody log Or custody record, which was not required, although the Custody Advisor informed the court that this was not meant to be the system. j) The care plan at the police station which was recorded in detail in the custody record (and is meant to record any risks and evidence of mental illness) was not sent onwards with the PER, nor was the section on the PER marked Care Plan completed, as the Custody Advisor informed it should be. Staff informed the court it never is. k) Staff at the first night centre assessment at HMP Highdown saw the basic information about his offence and recent history and the police national computer printout with no markers, although a subsequent one was found with markers, indicating a previous attempt in custody to himself in custody and a threat to stab anyone who takes his children. There was no cxplanation for a false negative sent: from 1og, - hang being
1) It is not clear if the nurse the health screen at HMP Highdown was shown or looked at the PER from the police station: m) It is not clear whether the nurse assessing health fitness for segregation in HMP Highdown by completing a proforma, did consult the System One Medical Records, but the nurse that he had no information on the prisoner'$ behaviour and health in the police station, nor over the preceding four weeks, which he needed, and that he expected the reception nurse to information to him and it was not for him to go to Reception to get it: n) The PER completed at HMP Highdown did not even reflect the limited information had received from the police station three earlier. It recorded no current health risks although the previous PER from the police station had indicated non compliance with MHA assessment and depression, a GP letter received reported a previous overdose in February and the decision had been made in reception that he needed mental health in reach service: The health care officer just recorded "fit for transfer"
0) The prison officer conducting the first night centre assessment in HMP Belmarsh did not see or consider the PER from police station to HMP Highdown, three previously: He did know he had a serious charge coming Up for sentence and had no family support and was going to be isolated for 23 Vz hours a in a single cell. He did not know he was depressed and on antidepressants, and if he had he would have opened an ACTT: Yet this information was known to health care staff: He reports that the nurse told him of no concerns and he told her of none: p) It was not apparent that the first night nurse assessment in HMP Belmarsh knew of or included consideration of his status on a care regime' which isolated him for his protection from other inmates. The nurse did not feel there was time nor was it his to review the medical records. He completed his proforma recording what the prisoner replied, even though he had information that it may be untrue and did not regard it was his to record or reconcile differences. The reception GP assessment in HMP Belmarsh did not consider his status isolated on a care regime although it was risk factor; nor had any knowledge of his behaviour in the police station or see any relevant information PNomis or discipline staff.
1) The GP the GP assessment in HMP Belmarsh informed the court that there was insufficient time in his to revicw the inmate medical records. He that the records showed that suicide six risk factors listed in Early Days in Custody were present recent change in circumstance, transfer another establishment; violent offence,history self harm and suicide,potentially category doing agreed bring days they days day 'duty job job agreed duty from doing job agreed
Aand history of mental illness and O1 alcohol problems. He had neither been informed of these factors nor identified them from the records and s0 neither opened an ACCT nor referred him to a psychiatrist: He was referred to the MH in-reach team by the nurse. That team reviewed his medical records, showing a history of alcohol abuse and depression on treatment (which did not apparently include any from the police station, which the psychiatrist said he does not routinely see) and were reassured by his not being followed up by a psychiatrist in the community after previous psychiatric admission, and by his presentation not raising any concerns for almost all the doctors and nurses, who had seen him in prisons. did not see any PERs, and was not informed he was isolated in a of care regime for 23 Vz hours a nor that the victims were children. The decision not to conduct a psychiatric assessment would have been different if he had scen the PERs or DPMFs or MHA assessment; or his in patient psychiatric notes The independent psychiatrist gave an opinion that the loss of information was a particular concern as people move in and out of custody so that there was a potential that information would be lost to the civilian GP. Whilst some organizations had taken a number of stcps to minimize the risks to the lives of others, particular the development of a national PER, others had only awoken to the risks in the closing days of the inquest: Virgin Health Care chose not to attend; Southern Health and Oxleas NHS Trust submitted plans to prevent future deaths before the inquest concluded. Hampshire Constabulary reported changes in training and staff awareness. Hampshire County Council prepared a short document of proposed actions, but it was not available as evidence as it was received by the court after the conclusion of the evidence: The evidence taken as a whole, suggested that there was a breakdown of communication at every professional and organizational interface, 18 of which are illustrated above. There was n0 system for transfer of health care information from police station court; or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or it if it was not in possession, whether there was also one to ask for it and if s0 which individual bore that responsibility: There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system; by rote with either no time to consider the whole person, O1 no sense that it was their responsibility to consider missing or discordant information Or to be proactive in communicating gaps in knowledge Or concerns. From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened.
2. That the standard of Mental Health Act assessments by these individuals needs to be improved, and, given all three were in agreement; that also training and provision for MHA assessments in police stations more widely may need to be reviewed_ drug They 'duty being day, key agreed complete
3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment o choice of assessors that mean that prisoners go to segregation when should be in the health care wing, or that go without observation, when they should be onan ACCT and receive extra support: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths: I believe that the following organizations or individuals have the power to take such action 1, The Secretaries of State of Home Office, Health and Ministry of Justice are notified of Matter no.1, the apparent defects in the system of communication. are asked to consider not only the adequacy of the instant organization'$ response, but whether there is a need to consider the risks are more appropriately addressed nationally:
2. In view of the conclusion of the jury with regard to neglect; the following are notified of Matter no. 2 about the adequacy and safety of MHA assessments_ are asked to consider whether they should refer themselves to their professional body, as their colleague b) The Department of Health is also asked to draw to the attention of those leading the Departmental Training programme for AMHPs the circumstances and findings of this inquest and consider whether further guidance or training with regard to the performance of Mental Health Act Assessments is required. 3 . Virgin Health Care is notified of Matter no. 3,the weaknesses and lack of training admitted by their nurse in conducting the fitness for segregation assessment and asked to consider whether the process is fit for purpose or whether redesign or further training is indicated. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by Tuesday December 20*h 2016. [, 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: If you require any further information Or assistance about the case, please contact the case officer, they they They has days
COPIES and PUBLICATION [have sent a copy of my report to the following Interested Persons: of Hickman and Rose Solicitors for the family, Government Legal for HMP Belmarsh, Capsticks Solicitors for Oxleas, Thompsons Solicitors for Prison Officers Association] Virgin Health Care, Hampshire PoliceDAC Beachcroft for and Stephen Fidler Solicitors for] Medical Protection Society: Ihave also sent it to The Royal College of Psychiatrists and independent psychiatric expert; who may find it useful or of interest: The court is to provide further documentation to the or t0 Ministers, if it would assist in their deliberations. Lam also under a to send a copy to the Chief Coroner as well as a copy of your response: 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 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: [DATE] [SIGNED BY CORONER] 2S (0 - (6 happy College duty may
Circumstances of the Death
An expert psychiatrist gave evidence, having considered his behaviour of unprovoked stabbing of 2 his delusions, hiding under a blanket in the police station, his obsession with a police woman, his outburst in prison, and study of a previous admission under mental health care that he suffered from De Clerambault syndrome (erotomania) and was suffering psychosis After arrest and They boys, charged with attempted murder; the deceased had delusions and refused to drink or eat for 48 hours with a stated intention to police officers that he would thus die on the 3rd He was remanded to HMP Highdown, where he was segregated; transferred to HMP Belmarsh 3 later; where he was isolated in a single cell, for his protection, for 23 !z hours a where he himself after 17 days.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.