Dear Ms Griffin,

Re: Regulation 28 Report to Prevent Future Deaths – Bradleigh Trevor Barnes who died on 28 December 2019

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 October 2022 concerning the death of Bradleigh Trevor Barnes on 28 December 2019. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Bradleigh’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Bradleigh’s care have been listened to and reflected upon.

You raised several concerns in your Report at section 5 (Coroner’s concerns), paragraphs 2 (i) to (iii). This letter has been prepared in response to the concern raised to NHS England at paragraph 2 (i), regarding the lack of national guidance to healthcare staff on the use of force in prison.

Firstly, I would like to clarify that the Prison Service Instructions (PSIs), Prison Service Orders (PSOs) and Policy Frameworks set out the framework for the operational running of a prison. NHS England and prison healthcare providers are required to ensure that all prison healthcare policies and service delivery are aligned to the appropriate PSI, PSO or policy framework. NHS England cannot deliver guidance that is not cognisant with these documents. In this case, as you have highlighted, PSO 1600 Use of Force is the operational instruction that includes the use of manual restraint, and section 6 outlines the roles of healthcare in the planned and unplanned use of force.

It may also be of assistance to mention that healthcare provision in a prison is commissioned using a principle of equivalence with what is provided in the community, such as primary care GP services, and community mental healthcare and nursing services. Prison healthcare is not always a 24/7 service, and even during hours where healthcare staff are present in the prison, there is no guarantee they would be asked, or available, to attend whilst prison officers are restraining a prisoner (where this is not a planned intervention). PSO 1600 sections 6.1 and 6.2 set out the circumstances in which healthcare staff are required to attend planned and unplanned control and restraint interventions. Specifically, for planned interventions, healthcare staff on duty National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

22 December 2022

‘MUST attend’ and, for unplanned interventions, a member of healthcare must, whenever reasonably practicable, attend every incident.

On 28 May 2015, the National Institute for Health and Care Excellence (NICE) published ‘Violence and aggression: short-term management in mental health, health and community settings’ (NG10)1. This national guidance was published with the aim of safeguarding both staff and service users, by providing evidence based best practice to support the prevention of violent situations and guidance to manage them safely when they occur, including the requirement to observe the physical and psychological health of the person under restraint for as long as clinically necessary. The guidance was written for all healthcare staff and provides a range of factors that must be considered to minimise the risk of harm to patients during and following a period of manual restraint. Although this guidance was written for settings where healthcare may well undertake control and restraint, there are sections that provide principles for roles and responsibilities, observations during restraint and monitoring physical and psychological health following a restraint, which are applicable for adoption in prison settings.

NHS England’s Patient Safety Team published a Patient Safety Alert (PSA) in December 2015, ‘The importance of vital signs during and after restrictive intervention/manual restraint’2. This PSA was written for all organisations providing NHS funded care, where restrictive interventions or manual restraint are used, and this included healthcare provided in prisons. It built on the NICE guidelines and required all healthcare providers, including those in the secure estate, to undertake four actions. This was followed up with NHS England’s regional health and justice commissioners.

Whilst the guidance and PSA referred to above were already in place around the time of Bradleigh’s death, NHS England recognises there is learning to be taken from the sad events in this case, and will be writing to all prison healthcare providers, via our seven regional commissioning teams, requiring them to work with their prison governor and have an agreed local operating procedure in place that includes:

• An outline of healthcare roles and responsibilities during and following a control and restraint incident, as described in PSO 1600: Use of Force.
• A requirement to monitor, record and act on vital signs during and after all control and restraint incidents they attend as per NICE Guidelines 10 and NHS England’s PSA from December 2015. This monitoring should use the National Early Warning Score (NEWS) 2 tool that is commonly used across the NHS to support clinical assessment and decision making in deteriorating patients.

NHS England’s central team will request assurance from our regional Directors of Commissioning that the above actions have been implemented and evidenced by April
2023. We are happy to provide you with a further update at this time if you consider this would assist?

1 Overview | Violence and aggression: short-term management in mental health, health and community settings | Guidance | NICE 2 psa-vital-signs-restrictive-interventions-031115.pdf (england.nhs.uk)

In addition to the above, NHS England will be working with colleagues in the HM Prison and Probation Service (HMPPS) to assist with their planned review and revision of PSO 1600: Use of Force. We will be supporting this review through providing clinical leadership on the revision and enhancement of section 6 and the roles and responsibilities of healthcare.

I hope the information above addresses the concern you have raised at paragraph 2 (i) of your Report, and provides some assurances that NHS England recognises there is learning and is working to address this in an adequate and timely manner.

I would also like to provide further assurances on the national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Bradleigh, are shared across the NHS at both a national and regional level, and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Ms Griffin, Regulation 28 report to Prevent Future Deaths Reports – Inquest touching the death of Bradleigh Trevor Barnes Thank you for your letter of 24th October 2022 containing a Regulation 28 to Prevent Future Deaths Reports (PFD), following the inquest into the death of Mr Bradleigh Trevor Barnes which concluded on the 20th October 2022. In the PDF you raised concerns in relation to the relationship between prison and healthcare teams namely: There is no local operating policy on the use of force at HMP YOI Portland between healthcare and prison; and you requested that the Governor of HMP YOI Portland and the Chief Executive of Oxleas NHS Foundation Trust consider putting a local instruction policy in place. We have now put in place a memorandum of understanding between healthcare and the prison regarding attendance of healthcare and all planned use of force interventions in accordance with the HM Prison Service, Prison Service Order: Order Number 1600 – Use of Force (see attached) Additionally, we have also agreed Healthcare staff are to be trained alongside prison officers in order to fully understand the techniques used and associated medical risks. I hope this provides you assurance that we have learned from this tragic event and will continue build on care of our patients. Your sincerely

Chief Executive Oxleas NHS Foundation Trust Pinewood House Pinewood Place Dartford Kent DA2 7WG oxleas.nhs.uk 13 December 2022

Rachel Clare Griffin, Senior Coroner Dorset Coroner’s Court Civic Centre, Bourne Avenue Bournemouth, BH2 6DY

Dear Mrs Griffin,

Thank you for your Regulation 28 report of 24 October 2022 addressed to , Director General of Operations for HMPPS, and the Governor of HMP Portland following the inquest into the death of Bradleigh Barnes at HMP Portland on 28 December 2019. This response addresses both concerns you have raised in relation to HMPPS. I understand that NHS England are responding separately.

I know that you will share a copy of this response with the family of Mr Barnes and I would like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

Following evidence heard at the inquest you have raised a concern that there was no local operating policy on the use of force between the prison and the healthcare provider. There is a new healthcare provider at the prison, Oxleas NHS Foundation Trust – Offender Healthcare Services. When healthcare providers are commissioned, part of the contract refers to the fact that they must adopt HMPPS policies and be guided by them. The contract began on 1 December 2022 and a memorandum of understanding (MOU) has been produced by the Governor of HMP Portland and the Service Director of Oxleas NHS Foundation Trust, setting out the role of healthcare during planned and unplanned use of force incidents as well as post incident actions to be followed to ensure the wellbeing of prisoners and staff. This MOU complies with the directions of Prison Service Order (PSO) 1600 which details the circumstances in which force can be used and the framework for justifying the use of force. The Use of Force policy document covers not only control and restraint techniques but also de-escalation skills, personal safety techniques and medical procedures including the role of healthcare staff in use of force incidents.

I am aware that NHS England are providing a separate response relating to issuing national Use of Force guidance for healthcare staff so I will not comment on this further but I wish to assure you that we continue striving to improve joined up working between prison and healthcare staff. The national use of force policy is currently being reviewed and updated, and healthcare colleagues are engaged as part of this process. I fully appreciate the important role that healthcare play in ensuring the safety of all prisoners and staff.

The second concern you have raised relates to the quality of mattresses provided by HMPPS which can lead to prisoners obtaining more than one for comfort and you have

asked that consideration be given to providing alterative better quality mattresses and issuing national guidance on prisoners accessing additional mattresses.

I can confirm that a review of Prison Service Instruction (PSI 11/2015) Fire Safety in Prison Establishments was carried out in March 2022. The policy sets out the fire retardancy standards for furniture and upholstery in prisons which are assessed as being a very high hazard for fires. For reference, hospitals are classed as medium hazard and hotels and residential homes for the elderly as high hazard. For this reason there are very stringent regulations that HMPPS are required to comply with when considering the beds, mattresses, and bedding to provide to prisons to ensure the safety of prisoners and staff.

The mattresses issued by HMPPS are 100mm thick and are produced to a very specific standard with each batch scientifically tested to ensure that they meet the very rigorous fire retardancy standards. It is unfortunate that, in order to achieve safety standards, the mattresses can be quite hard, however the safety of those in our care must be paramount.

I can confirm that the metal bedframes at HMP Portland have been replaced by new whitewood furniture beds and am assured that the feedback received from the prison is that there has been a positive response to the new beds from prisoners.

In order to reduce the risk of mattresses being used as a barricade, prisons must manage this locally in the same way that they monitor the potential use of other cell furniture as a barricade, and staff must challenge prisoners who have additional mattresses and remove them. This is monitored through daily accommodation fabric checks which are recorded and assured locally to ensure safety and security.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised.

Dear Mrs Griffin

You have requested that I provide a response to a Regulation 28 report which you issued following the inquest into the death of Bradleigh Barnes at HMP Portland on 28 December 2019.

As you are aware, in December 2022 , Director General Operations, on behalf of His Majesty’s Prison and Probation Service (HMPPS), wrote to you providing a response to the concerns you had raised in relation to the Prison Service. I, as Governing Governor of HMP Portland, with responsibility for the prison, provided relevant information to contribute to the response.

HMPPS is committed to learning from deaths in custody and preventing future deaths, and learning from regulation 28 reports helps to inform national actions and feed into local actions which Governing Governors are responsible for embedding and managing at their prisons. Phil Copple, as the most senior appropriate person to provide assurances of the actions being taken at a local and national level across the organisation, considers and responds to all Regulation 28 reports issued to HMPPS. I understand that you require a separate response from me confirming this.

I hope that this letter provides assurance that the response already received is on behalf of the whole agency, HMPPS, but that I was involved in the consultation and drafting of the response, providing assurance to of the actions taken locally at HMP Portland.