David Kirsch
PFD Report
All Responded
Ref: 2019-0362
All 1 response received
· Deadline: 3 Feb 2020
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
3 Feb 2020
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
During course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken _ (1) No Case Manager had been allocated to oversee Mr. Kirsch's ACCT document This lack of oversight resulted in a number of deficiencies in the ACCT process, including: (a) 11 different people chairing the 13 ACCT reviews which took place in the 6 weeks between Mr. Kirsch'$ return from hospital on 5.2.18 and his death on 19.3.18; (b) Inadequate completion of the Caremap within the ACCT document; which ought to have highlighted the issues behind Mr. Kirsch's concerning behaviour and suicide attempts in January 2018,and identified actions to be taken to try to address those issues In this case, evidence was heard that: When he had first started his sentence in 2008, Mr. Kirsch had told people that he would not live to complete it; In August 2017 hehad had notable episodes of bizarre behaviour and being: the two which, it was thought; may have been down to having taken the psychoactive substance Spice (iii) Evidence from staff who had witnessed the suicide attempts in January 2018 indicated that they thought he may have taken Spice on those occasions; Throughout 2017 and early 2018 he had been rather obsessed with a complaint he had made about an entry on his NOMIS record, and that in the days leading up to his death he had reported that this had been keeping him up at night; He was concerned that his daughter; who had become an adult relatively recently, had not tried to make contact with (vi) He was worried about visits from his family, and how he was going to tell them what he had done in January 2018; (vii) He had been involved in a fight on 13.3.18 with another prisoner something out of character for him ) , which had resulted in his transfer to another wing; away from a fellow prisoner who was an important of his support network; (viii) He had recently sought out a member of the healthcare team in tears because he was worried that he had not been able to across his version of events in the adjudication hearing held after the fight incident; (ix) On the afternoon of his death fellow prisoners had expressed concerns t0 a Supervising Officer that Mr: Kirsch was "looking particularly down' and was not himself. This conversation was passed on to the Supervising Officer on Mr: Kirsch's wing who spoke to him: In that conversation, Mr: Kirsch made a concerning comment about having bitten someone, and denied untruthfully that he had had any involvement with the mental health team at the prison These concerns and conversations were not recorded anywhere in the main body of the ACCT document Save for the fact of the fight on 13.3.18 and of his resulting transfer to another wing, none of these matters was noted in the Caremap on Mr. Kirsch's ACCT document; and so no actions were identified to try to address them: (c) The ACCT document was opened on 20.1.18. Between then and 5.2.18 Mr. Kirsch had been receiving treatment for his injuries in hospital, and had been on constant bedwatch there. When he returned to the prison on 5.2.18, no entries were made to the Caremap at all for the first four weeks thereafter.
(2) The person whose namehad been entered as Case Manager on the ACCT document tonfirmed in evidence that he was not aware of this, and had never nad any involvement with this ACCT document because he had not been told about it More worryingly, another unknown person appears to have signed off the first page of the Caremap using initials.
(3) Despite the ACCT document having been open for more than 6 weeks, it was not escalated to a more senior member of staff;, as per prison policy: (4) Some prison officers appeared to have had a worrying lack of knowledge of the reasons for the ACCT document opened, and of the issues set out therein which needed to be monitored. By way of example: the Supervising Officer on Mr. Kirsch's wing who had the conversation with him described at 1(b)(ix) above, was not aware that DK had attempted suicide twice in January 2018,and had not realised that Mr. Kirsch was being untruthful about his involvement with the mental health team; (b) another Supervising Officer who had conducted an earlier ACCT review on 8.2.18 also conceded_in evidence_that at the time _he conducted the review him; part get two being (a)
he had "probably not" had any idea about the two suicide attempts the previous month. The Supervising Officer who conducted the last ACCT review on 16.3.18 conceded in evidence that; in the course of that review; he may not have asked Mr: Kirsch about his state of mind or whether he was having any thoughts of suicide or self-harm. When asked how he had proposed to assess Mr. Kirsch's level of risk and to complete the Caremap, he stated that he would have done so on the way Mr: Kirsch presented at that review, and by the fact that he was calm, collected and polite throughout their conversation.
(2) The person whose namehad been entered as Case Manager on the ACCT document tonfirmed in evidence that he was not aware of this, and had never nad any involvement with this ACCT document because he had not been told about it More worryingly, another unknown person appears to have signed off the first page of the Caremap using initials.
(3) Despite the ACCT document having been open for more than 6 weeks, it was not escalated to a more senior member of staff;, as per prison policy: (4) Some prison officers appeared to have had a worrying lack of knowledge of the reasons for the ACCT document opened, and of the issues set out therein which needed to be monitored. By way of example: the Supervising Officer on Mr. Kirsch's wing who had the conversation with him described at 1(b)(ix) above, was not aware that DK had attempted suicide twice in January 2018,and had not realised that Mr. Kirsch was being untruthful about his involvement with the mental health team; (b) another Supervising Officer who had conducted an earlier ACCT review on 8.2.18 also conceded_in evidence_that at the time _he conducted the review him; part get two being (a)
he had "probably not" had any idea about the two suicide attempts the previous month. The Supervising Officer who conducted the last ACCT review on 16.3.18 conceded in evidence that; in the course of that review; he may not have asked Mr: Kirsch about his state of mind or whether he was having any thoughts of suicide or self-harm. When asked how he had proposed to assess Mr. Kirsch's level of risk and to complete the Caremap, he stated that he would have done so on the way Mr: Kirsch presented at that review, and by the fact that he was calm, collected and polite throughout their conversation.
Responses
Response received
View full response
Dear Mr Reid
Thank you for your Regulation 28 report of 30 October 2019 addressed to the Governor of HMP Long Lartin, following the inquest into the death of David John Kirsch at the prison on 19 March 2018. I am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS), and will describe the work that and his team are taking forward locally as well as some developments at national level that are relevant to the concerns that you have raised.
I know that you will share a copy of this response with Mr Kirsch’s family, and I would like first to express my condolences for their loss. The safety of those in our care is my absolute priority, and every death in custody is a tragedy.
You have identified five matters of concern and I will respond to each in turn.
(1) No Case Manager had been allocated to oversee Mr Kirsch’s ACCT document. This lack of oversight resulted in a number of deficiencies in the ACCT process.
Consistency of case management, effective completion of Caremaps and the importance of information sharing are all covered in the revised training for ACCT case managers that has been introduced nationally. Guidance on these points has been sent to all existing case managers at Long Lartin and, between November 2019 and June 2020, all Band 4 and Band 5 operational staff will attend initial or refresher training in ACCT case management.
(2) The person whose name had been entered as Case Manager on the ACCT document confirmed in evidence that he was not aware of this, and had never had any involvement with this ACCT document because he had not been told about it. More worryingly, another unknown person appears to have signed off the first page of the Caremap using initials.
A full investigation has been commissioned into the apparent appending of
details on an ACCT document without his knowledge. This is scheduled for completion by the end of January 2020.
An online log of all open ACCT documents, complete with details of the assigned case manager, is now accessible to all staff at the prison. This forms part of the daily briefing document shared with all staff. This prompts case managers to take ownership of their cases, as well as avoiding any confusion about who has been assigned each case.
(3) Despite the ACCT document being open for more than 6 weeks it was not escalated to a more senior member of staff, as per prison policy.
At Long Lartin, a weekly multi-disciplinary safety intervention meeting is convened where cases that are complex and/or require a higher level of input are now discussed. This provides an opportunity to discuss cases approaching the six-week point in order to identify a more senior member of staff to take over as case manager and/or to devise an enhanced care plan as appropriate.
(4) Some prison officers appeared to have had a worrying lack of knowledge of the reasons for the ACCT document being opened, and of the issues set out therein which needed to be monitored.
Introduction to Suicide and Self Harm Prevention (SASH) training is being delivered to all HMPPS staff with prisoner contact, and is also offered to staff of partners and contractors. The course is made up of six modules, including ‘Recognising Risks and Triggers’, ‘Opening ACCT Documents’, and ‘An Introduction to Mental Health Awareness’.
At Long Lartin, a comprehensive training plan has been put in place that will see regular full-day training courses being delivered to groups of staff. All operational staff will be trained by August 2020, and all non-operational staff and staff from partner agencies by November 2020. To facilitate this, several members of staff from the prison are being trained as SASH trainers in January 2020.
(5) The Supervising Officer who conducted the last ACCT review on 16.3.18 conceded in evidence that, in the course of that last review, he may not have asked Mr. Kirsch about his state of mind or whether he was having any thoughts of suicide or self- harm. When asked how he had proposed to assess Mr. Kirsch’s level of risk and to complete the Caremap, he stated that he would have done so on the way Mr. Kirsch presented at that review, and by the fact that he was calm, collected and polite throughout their conversation.
As explained at (1) above, all existing case managers at Long Lartin have been provided with additional guidance, and all staff taking on this role will be attending initial or refresher training by June 2020. This training is clear that judgements about risk must be made on the basis of a range of information and thorough engagement with the individual, as well as their presentation at the review meeting.
A number of the matters that you have raised are related to deficiencies in the implementation of the ACCT process that are not confined to this case or to Long Lartin. We are working hard to address these through the training described in the responses to the specific points. More generally, we have reviewed the ACCT process and devised a new version of the form and associated guidance. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was
piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal evaluation report and expect to make some further changes before rolling out the new version of ACCT across the prison estate later in 2020. I am confident that this will bring further improvements to the work that staff do to keep prisoners safe.
Thank you again for bringing these concerns to my attention. I hope this response has provided assurance that they are being addressed.
Thank you for your Regulation 28 report of 30 October 2019 addressed to the Governor of HMP Long Lartin, following the inquest into the death of David John Kirsch at the prison on 19 March 2018. I am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS), and will describe the work that and his team are taking forward locally as well as some developments at national level that are relevant to the concerns that you have raised.
I know that you will share a copy of this response with Mr Kirsch’s family, and I would like first to express my condolences for their loss. The safety of those in our care is my absolute priority, and every death in custody is a tragedy.
You have identified five matters of concern and I will respond to each in turn.
(1) No Case Manager had been allocated to oversee Mr Kirsch’s ACCT document. This lack of oversight resulted in a number of deficiencies in the ACCT process.
Consistency of case management, effective completion of Caremaps and the importance of information sharing are all covered in the revised training for ACCT case managers that has been introduced nationally. Guidance on these points has been sent to all existing case managers at Long Lartin and, between November 2019 and June 2020, all Band 4 and Band 5 operational staff will attend initial or refresher training in ACCT case management.
(2) The person whose name had been entered as Case Manager on the ACCT document confirmed in evidence that he was not aware of this, and had never had any involvement with this ACCT document because he had not been told about it. More worryingly, another unknown person appears to have signed off the first page of the Caremap using initials.
A full investigation has been commissioned into the apparent appending of
details on an ACCT document without his knowledge. This is scheduled for completion by the end of January 2020.
An online log of all open ACCT documents, complete with details of the assigned case manager, is now accessible to all staff at the prison. This forms part of the daily briefing document shared with all staff. This prompts case managers to take ownership of their cases, as well as avoiding any confusion about who has been assigned each case.
(3) Despite the ACCT document being open for more than 6 weeks it was not escalated to a more senior member of staff, as per prison policy.
At Long Lartin, a weekly multi-disciplinary safety intervention meeting is convened where cases that are complex and/or require a higher level of input are now discussed. This provides an opportunity to discuss cases approaching the six-week point in order to identify a more senior member of staff to take over as case manager and/or to devise an enhanced care plan as appropriate.
(4) Some prison officers appeared to have had a worrying lack of knowledge of the reasons for the ACCT document being opened, and of the issues set out therein which needed to be monitored.
Introduction to Suicide and Self Harm Prevention (SASH) training is being delivered to all HMPPS staff with prisoner contact, and is also offered to staff of partners and contractors. The course is made up of six modules, including ‘Recognising Risks and Triggers’, ‘Opening ACCT Documents’, and ‘An Introduction to Mental Health Awareness’.
At Long Lartin, a comprehensive training plan has been put in place that will see regular full-day training courses being delivered to groups of staff. All operational staff will be trained by August 2020, and all non-operational staff and staff from partner agencies by November 2020. To facilitate this, several members of staff from the prison are being trained as SASH trainers in January 2020.
(5) The Supervising Officer who conducted the last ACCT review on 16.3.18 conceded in evidence that, in the course of that last review, he may not have asked Mr. Kirsch about his state of mind or whether he was having any thoughts of suicide or self- harm. When asked how he had proposed to assess Mr. Kirsch’s level of risk and to complete the Caremap, he stated that he would have done so on the way Mr. Kirsch presented at that review, and by the fact that he was calm, collected and polite throughout their conversation.
As explained at (1) above, all existing case managers at Long Lartin have been provided with additional guidance, and all staff taking on this role will be attending initial or refresher training by June 2020. This training is clear that judgements about risk must be made on the basis of a range of information and thorough engagement with the individual, as well as their presentation at the review meeting.
A number of the matters that you have raised are related to deficiencies in the implementation of the ACCT process that are not confined to this case or to Long Lartin. We are working hard to address these through the training described in the responses to the specific points. More generally, we have reviewed the ACCT process and devised a new version of the form and associated guidance. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was
piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal evaluation report and expect to make some further changes before rolling out the new version of ACCT across the prison estate later in 2020. I am confident that this will bring further improvements to the work that staff do to keep prisoners safe.
Thank you again for bringing these concerns to my attention. I hope this response has provided assurance that they are being addressed.
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action by conducting an investigation into the deficiencies and failures outlined above, and by conducting a review of the ACCT process within your prison:
Report Sections
Investigation and Inquest
On 29.3.18 an investigation was commenced into the death of David John KIRSCH, prisoner at HMP Long Lartin, who was then 52 years of age This investigation concluded at the end of the inquest on 29.10.19. The conclusion of the inquest was that Mr. Kirsch died as the result of suicide, the medical cause of death 1a Haemorrhage; 1b Incised wound right side of neck_
Circumstances of the Death
Mr: Kirsch, who had previously attempted to take his own life on 20.1.18 and 21.1.18, was found deceased in his cell on the evening of 19.3.18, having used the lid of a tin to inflict a large wound to his neck which involved the external jugular vein At the time of his death, Mr. Kirsch had been the subject of an ACCT document since 20.1.18.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Recording Clinical Discussions
Hyponatraemia Inquiry
No person-centred care
Inaccurate and inaccessible patient records
CDI patient information
Vale of Leven Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Provide evidence-based patient information in a comprehensible summary format
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Regularly update and pilot patient information materials with active patient involvement
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
NHS Modernisation Agency to prioritise patient information quality and establish accreditation system
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Develop kitemarking system for reliable internet health information guidance for public
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.