Dear Madam Coroner, REGULATION 28 REPORT TO PREVENT FURTHER DEATHS I refer to the subject reference which was issued following the inquest into the death of Zak Miles Joe Walter Paul Farmer and which was received by the Castle Rock Group on Monday 5 October 2020. The concerns raised in your report were as follows “1.Mr Farmer had spent some time, during his custodial sentence at HM Prison Chelmsford as a patient at the medium secure unit at Brockfield House pursuant to s48 MHA 1983. There appears to have been a failing in CRG’s procedures for obtaining information from the hospital following the discharge so that a prisoner receives his prescribed medication.
2. There appears to have been a failing in CRG’s procedures to ensure that a prisoner is released with discharge information relating to diagnoses. prescription and care plan details”. In respect of concern number 1 above, a member of the mental health team attends all MHA s117 meetings prior to a prisoner being discharged back to HMP Chelmsford. The information contained within the s117 meeting minutes will determine the pathway, care plan and medicines management for that person. This information is discussed at the weekly multi-disciplinary team (MDT) meeting hosted by the mental health team. Minutes of these meetings are recorded on SystmOne and can be examined if required. The mental health team now have a dual system (SystmOne and a card index system) both of which contain up to date records of current patients being seen by the unit. This provides a safeguard should SystmOne be offline for any length of time. This dual system is audited each week to ensure both are accurate and updated and the ability exists to run reports on the number of patients released from prison on a month by month basis. In the event that a prisoner is transferred from Brockfield House to HMP Chelmsford via court, rather than being directly transferred, any relevant confidential medical information is sent from Brockfield House to the healthcare team at HMP Chelmsford via secure email facility. This secure email facility has replaced the previous postal/fax system that was in place at the time of Mr Farmer’s transfer between the two institutions. 8 Tiger Court Kings Business Park Prescot Merseyside L34 1BH Phone: 0174 445 2980 Fax: 0845 680 1619 Email: info@crg.uk.com Web:

The standard and frequency of communication between the mental health team and staff at Brockfield House is very much improved and there is regular dialogue with regards to any prisoner who has spent, or is about to spend, time at that unit. Again, evidence of this communication is available for scrutiny on SystmOne.

In conclusion, physical attendance at the s117 meetings, follow-up discussion and planning by the MDT and the use of secure email has markedly improved and standardised the prisoner transfer process.

Regarding concern number 2; the process of discharge has changed significantly since CRG took over responsibility for healthcare provision at HMP Chelmsford in April 2019 and the ability now exists for GPs to access clinical notes which are stored and managed on SystmOne. This access is available through ‘NHS Spine’ which is a relatively new development which was unfortunately not available at the time of Mr Farmer’s discharge from prison. In the event that a prisoner does not already have a community-based GP, advice is given by healthcare staff to assist the prisoner with how to register with a community GP. This advice is recorded on SystmOne and is available for examination. A discharge summary (this would include the care plan, medication and diagnosis details), also now accompanies the prisoner on release from prison. Records of the discharge summary are kept on SystmOne and are available for examination. These records are also accessible by GPs through NHS Spine as described above. Additionally, CRG employ a social inclusion representative who has responsibility for ensuring that when a prisoner is discharged, arrangements are made on behalf of the prisoner so that the provision of clinical details and other social arrangements are in place prior to discharge from prison. A record of individual prisoners’ discharge arrangements is stored on SystmOne and is available for examination. The discharge process is monitored and supervised by a senior member of the mental health team. I hope that the explanation of how current healthcare operations described in the paragraphs above differ significantly from the procedures in place immediately after CRG assumed responsibility for healthcare provision at HMP Chelmsford fully answer the concerns you raised in your PFD report. Please do let me know if I can be of any further assistance or indeed if you would like a presentation of SystmOne in relation to the record keeping referred to in the main body of this letter.

Dear Mrs Beasley-Murray,

I am writing to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 24th September 2020, which was issued following the inquest into the death of Mr Zak Farmer.

I would like to begin by extending my deepest condolences to the family of Mr Farmer. This has been an extremely difficult time for them and I hope that my response provides the family, and you, with assurance that the Trust takes their loss seriously and has taken action to address the issues of concern raised in your report.

In response to the matter of concern regarding a lack of clarify over the meaning of the word “urgent” when a referral is made to the Access and Assessment Team and what steps will be taken if a patient cannot be contacted; I can confirm that the Access and Assessment Service respond to all referrals in line with nationally accepted guidelines and standards. A crisis response is responded to within 4 hours, an urgent response within 24 hours and a routine response within 28 days. All referrals are triaged by the team to establish the response required and risk ‘red flags’ are used to inform this decision. The ‘red flags’ are as follows:

Risk assessment red flags:  Gambling issues  Drug / alcohol issues  Complex social situation e.g. relationship breakdown  Financial issues, debt, redundancy  Male, middle or younger age  High risk occupations – police officers, doctors, farmers, prison officers  Complex physical health issues  Chronic pain  Family concern / contacting services  Context and history – have there been multiple recent presentations/referrals?

Since April 2020 the Trust has established a separate Crisis Response Service and all crisis referrals are now actioned by this team.

In response to the matter of concern regarding the EPUT Clinical Guidelines for Community Mental Health Service Users disengaging or non-concordant with current prescribed treatment

plan, I can confirm that this document is currently under review and we will ensure that it is comprehensive and provides clear guidance for staff.

I hope that I have provided you with robust assurance that the Trust has taken steps to address the issues of concern in your report, that we are continuing to take action to strengthen the care provided to our patients, and that patient safety is the Trust’s top priority.