Jacob Billington
PFD Report
All Responded
Ref: 2024-0136
All 5 responses received
· Deadline: 8 May 2024
Response Status
Responses
5 of 5
56-Day Deadline
8 May 2024
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
1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning they are not traced and treated assertively in the community.
2. Systmone Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Systmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
2. Systmone Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Systmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
Responses
West Midlands Police updated MAPPA procedures and policy in September 2023, creating new data fields to improve identification of high-risk individuals. They will work with MAPPA partners to ensure the prison discharge coordinator role and policy are fully understood and cascaded to all police MAPPA staff.
AI summary
View full response
Dear Mrs Hunt,
Prevention of Future Deaths report dated 13 March 2024
I write in response to the Prevention of Future Deaths report dated the 13 March 2024 which followed on from the inquest concerning the death of Mr Jacob Billington. The report identified four key areas of concern, namely:
1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high-risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning they are not traced and treated assertively in the community.
2. Systmone. Details of the perpetrator’s GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Systmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
Keeping our Communities Safe and Reassured
Working in partnership, making communities safer STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES
Director of Legal Services
Your Ref:
Our Ref:
Email:
Date: 8 May, 2024
3. Cross agency guidance regarding release of high-risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross-agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
This letter is the response on behalf of the Chief Constable of West Midlands Police. Given the issues identified within the report, in preparing this response West Midlands Police have liaised with HM Prisons and Probation Service (HMPPS). As the lead agency for the Multi-Agency Public Protection Arrangements (MAPPA), I understand HMPPS will also provide a response.
Management of release and lack of interagency working
MAPPA is a national framework to assess and manage the risk posed by serious and violent offenders. It is not a statutory body in itself but is a mechanism through which agencies can better discharge their statutory responsibilities and protect the public in a co-ordinated manner. Agencies at all times retain their full statutory responsibilities and obligations. They need to ensure that these are not compromised by MAPPA. In particular, no agency should feel pressured to agree to a course of action which they consider is in conflict with their statutory obligations and wider responsibility for public protection.
West Midlands Police are fully engaged at all levels of MAPPA, including attendance at the Strategic Management Board (SMB), which is the means by which the partnership fulfils its duties to keep the MAPPA arrangements under review. The SMB monitors the effectiveness of MAPPA, making any changes that appear necessary or expedient. The SMB is therefore responsible for managing MAPPA activity in its area. This includes reviewing its operations for quality, and effectiveness and planning how to accommodate any changes as a result of legislative changes, national guidance or wider criminal justice changes. The SMB are responsible for the implementation of the MAPPA Guidance in their area, in line with local initiatives and priorities. WMP will ensure a senior leader is present at SMB, this will be at least a Chief Superintendent and, where possible, other senior leaders and the Assistant Chief Constable with responsibility for MAPPA will also attend. We will ensure that all offenders subject to notification requirements:
• Register as required.
• Are assessed in accordance with a nationally approved risk assessment and management system.
• Are visited at their registered address in line with the approved Risk Management Plan (RMP) and national guidance.
• Are managed in line with approved professional practice.
• Are entered on ViSOR and have their ViSOR records maintained in accordance with national ViSOR standards. The vast majority of MAPPA offenders will be managed through the ordinary management of one agency, although this will usually involve the sharing of information with other relevant agencies. The structural basis for the discussion of MAPPA offenders who need active inter-agency management, including their risk assessment and risk management, is the MAPPA meeting. The Responsible Authority agencies and the MAPPA Co-ordinator are permanent members of these meetings. Other agencies are invited to attend for any offender in respect of whom they can provide additional support and management. The frequency of meetings depends on the level of management deemed appropriate for each offender.
West Midlands Police will attend all Level 2 and 3 meetings. The officer attending the meetings will be senior enough in rank to allocate police resources. Best practice involves attendance from an Inspector at all Level 2 meetings and Chief Inspector at all Level 3 meetings. However, a lower-ranking officer may attend where necessary if they have experience of the MAPPA process and delegated authority to allocate police resources at the appropriate level.
Visor is the shared IT system accessible to numerous agencies. West Midlands Police will ensure we continue to update Visor records for each individual to ensure information can be shared across agencies.
We will work with all agencies to understand key roles and systems to better share information, manage individuals and protect the public.
Finally, as explained in evidence during the inquest: West Midlands Police’s approach to visiting managed offenders has changed since Mr Billington’s death. The position now is that a West Midlands Police officer will try to visit a managed offender when they are released from prison, regardless of the status of the MAPPA process.
Systmone
As Systmone is an IT system used by healthcare professionals, West Midlands Police did not (and do not) have access to this system.
Cross agency guidance regarding release of high-risk prisoners with mental health difficulties at their sentence end date
This issue will be addressed by HMPPS, however we will ensure we provide support from a policing perspective to partners in relation to high-risk prisoners with mental health difficulties at their sentence end date. From a policing perspective, it is important to note that the IT systems now in place (as described in evidence during the inquest) have changed meaning that there are now better opportunities to identify someone if they have been assessed as being at an increased risk to themselves or others.
West Midlands MAPPA has a prison discharge coordinator role
The issue will be addressed by the partners who manage the prisoner coordinator role and who amend the new policy. West Midlands Police will work with our MAPPA partners to ensure both the role and policy are both understood and cascaded to all staff within the police MAPPA teams.
If WMP can be of further assistance in relation to this matter, please do not hesitate to contact me.
Prevention of Future Deaths report dated 13 March 2024
I write in response to the Prevention of Future Deaths report dated the 13 March 2024 which followed on from the inquest concerning the death of Mr Jacob Billington. The report identified four key areas of concern, namely:
1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high-risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning they are not traced and treated assertively in the community.
2. Systmone. Details of the perpetrator’s GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Systmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
Keeping our Communities Safe and Reassured
Working in partnership, making communities safer STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES
Director of Legal Services
Your Ref:
Our Ref:
Email:
Date: 8 May, 2024
3. Cross agency guidance regarding release of high-risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross-agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
This letter is the response on behalf of the Chief Constable of West Midlands Police. Given the issues identified within the report, in preparing this response West Midlands Police have liaised with HM Prisons and Probation Service (HMPPS). As the lead agency for the Multi-Agency Public Protection Arrangements (MAPPA), I understand HMPPS will also provide a response.
Management of release and lack of interagency working
MAPPA is a national framework to assess and manage the risk posed by serious and violent offenders. It is not a statutory body in itself but is a mechanism through which agencies can better discharge their statutory responsibilities and protect the public in a co-ordinated manner. Agencies at all times retain their full statutory responsibilities and obligations. They need to ensure that these are not compromised by MAPPA. In particular, no agency should feel pressured to agree to a course of action which they consider is in conflict with their statutory obligations and wider responsibility for public protection.
West Midlands Police are fully engaged at all levels of MAPPA, including attendance at the Strategic Management Board (SMB), which is the means by which the partnership fulfils its duties to keep the MAPPA arrangements under review. The SMB monitors the effectiveness of MAPPA, making any changes that appear necessary or expedient. The SMB is therefore responsible for managing MAPPA activity in its area. This includes reviewing its operations for quality, and effectiveness and planning how to accommodate any changes as a result of legislative changes, national guidance or wider criminal justice changes. The SMB are responsible for the implementation of the MAPPA Guidance in their area, in line with local initiatives and priorities. WMP will ensure a senior leader is present at SMB, this will be at least a Chief Superintendent and, where possible, other senior leaders and the Assistant Chief Constable with responsibility for MAPPA will also attend. We will ensure that all offenders subject to notification requirements:
• Register as required.
• Are assessed in accordance with a nationally approved risk assessment and management system.
• Are visited at their registered address in line with the approved Risk Management Plan (RMP) and national guidance.
• Are managed in line with approved professional practice.
• Are entered on ViSOR and have their ViSOR records maintained in accordance with national ViSOR standards. The vast majority of MAPPA offenders will be managed through the ordinary management of one agency, although this will usually involve the sharing of information with other relevant agencies. The structural basis for the discussion of MAPPA offenders who need active inter-agency management, including their risk assessment and risk management, is the MAPPA meeting. The Responsible Authority agencies and the MAPPA Co-ordinator are permanent members of these meetings. Other agencies are invited to attend for any offender in respect of whom they can provide additional support and management. The frequency of meetings depends on the level of management deemed appropriate for each offender.
West Midlands Police will attend all Level 2 and 3 meetings. The officer attending the meetings will be senior enough in rank to allocate police resources. Best practice involves attendance from an Inspector at all Level 2 meetings and Chief Inspector at all Level 3 meetings. However, a lower-ranking officer may attend where necessary if they have experience of the MAPPA process and delegated authority to allocate police resources at the appropriate level.
Visor is the shared IT system accessible to numerous agencies. West Midlands Police will ensure we continue to update Visor records for each individual to ensure information can be shared across agencies.
We will work with all agencies to understand key roles and systems to better share information, manage individuals and protect the public.
Finally, as explained in evidence during the inquest: West Midlands Police’s approach to visiting managed offenders has changed since Mr Billington’s death. The position now is that a West Midlands Police officer will try to visit a managed offender when they are released from prison, regardless of the status of the MAPPA process.
Systmone
As Systmone is an IT system used by healthcare professionals, West Midlands Police did not (and do not) have access to this system.
Cross agency guidance regarding release of high-risk prisoners with mental health difficulties at their sentence end date
This issue will be addressed by HMPPS, however we will ensure we provide support from a policing perspective to partners in relation to high-risk prisoners with mental health difficulties at their sentence end date. From a policing perspective, it is important to note that the IT systems now in place (as described in evidence during the inquest) have changed meaning that there are now better opportunities to identify someone if they have been assessed as being at an increased risk to themselves or others.
West Midlands MAPPA has a prison discharge coordinator role
The issue will be addressed by the partners who manage the prisoner coordinator role and who amend the new policy. West Midlands Police will work with our MAPPA partners to ensure both the role and policy are both understood and cascaded to all staff within the police MAPPA teams.
If WMP can be of further assistance in relation to this matter, please do not hesitate to contact me.
G4S has issued an email notice to all offender managers at HMP & YOI Parc, requiring them to notify the Community Offender Manager about prisoners being released at sentence end date without fixed abode, to improve interagency coordination. G4S will also continue to streamline its own data recording within the DPS system.
AI summary
View full response
Dear Madam
Jacob Michael Nicholas Billington
2
Client Confidential
4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
Response
G4S confines its response to the first concern identified relating to the management of release from prison and interagency working.
G4S has no power to take action regarding concerns 2, 3 and 4, and, therefore, is not in a position to assist HM Senior Coroner with regard to these concerns. Other interested persons to whom the Regulation 28 report has been addressed are better able to consider the concerns raised, take action and/or explain why no action is proposed.
In addition, G4S has no power to influence the management of release of prisoners from, and/or to ensure interagency working at, private prisons operated by other providers or HMPPS operated prisons.
Offender management in all prisons across England and Wales, including all privately operated prisons, is delivered pursuant to a HMPPS prescribed delivery model. Prisoners are case managed through their custodial sentence by a prison based Offender Management Unit (OMU) pursuant to the national Offender Management in Custody (OMiC) model, which provides a framework to coordinate and set out the sequence for a prisoner’s journey through custody to post-release. This model applies to all prisons in England and Wales.
Qualified probation officers and senior probation officers employed by the Probation Service/HMPPS are based at HMP & YOI Parc. All high-risk prisoners are managed by qualified Probation Service offender managers working at the prison.
HMPPS has responsibility for provision and operation of resettlement services. Such resettlement services at HMP & YOI Parc are commissioned by HMPPS from external providers who are based within the prison to facilitate resettlement services for prisoners approaching release from custody. G4S is not party to the procurement or placement of resettlement services within HMP & YOI Parc or the direct delivery of these services. G4S’ focus is on ensuring alignment and integration with third party service providers to ensure effective interagency working.
Resettlement services have responsibility for providing resettlement support to prisoners, including coordinating referrals and signposting to services such as housing and DWP benefits.
Responsibility for case management of any prisoner under the OMiC model passes to the Probation Service Community Offender Manager when a prisoner reaches a point which is eight and a half months prior to their release date. This includes responsibility for managing the prisoner’s release and coordinating liaison between relevant agencies involved and includes the sharing of information with all other relevant agencies and individuals working with the prisoner. The Community Offender Manager takes responsibility for coordinating the prisoner’s resettlement support, addressing and escalating any concerns relating to risk, and undertaking any required pre-release risk assessments, including OASys, a risk assessment conducted by the Community Offender Manager at various stages of the prisoner’s time in custody. Where a prisoner is recalled to custody their case management is the responsibility of the Probation Service Community Offender Manager with support from the prison based Prison Offender Manager.
3
Client Confidential Prior to release, the Community Offender Manager must review the OASys assessment and prepare a pre- release report/assessment of the prisoner using the OASys tool. This should place particular focus on resettlement needs and further actions required to safeguard against any concerns regarding potential risks of causing harm and/or of reoffending.
Further Action
Prior to conclusion of the inquest touching the death of Mr Billington, G4S had the opportunity to participate in and consider the outcomes of the NICHE report commissioned by the NHS, and a MAPPA serious case review, two detailed investigations into the material incident. No recommendations were made relating to G4S in respect of the discharge from prison in either of the reports, however, G4S carefully noted the findings and carefully noted evidence provided at the inquest touching the death of Mr Billington.
Having considered the two investigation reports and having listened to the evidence, steps have been taken by G4S at HMP & YOI Parc to reinforce information sharing and communication surrounding the release of a prisoner from custody.
• Resettlement services drop-in sessions have been introduced and approved laptops have been received from HMPPS to roll out remote sessions under resettlement activities, to encourage engagement with resettlement services by prisoners approaching release and to provide opportunities to gather further information.
• Monthly strategy meetings at the prison show consistently high (c 90%) levels of prisoners released from custody are housed on the first night of their release, so that their whereabouts immediately post release is known to relevant community services.
• At HMP & YOI Parc, a member of the cashiers team issues a travel warrant for each prisoner shortly before they are released from custody. The cashier previously recorded on CMS, the prison’s central electronic messaging system, the fact that a travel warrant had been issued. The cashier now records where the travel warrant has been issued to, and, in addition, sends an email to a new OMU email group, which includes healthcare admin and the Heads of Offender Management, to indicate that a travel warrant has been issued with details of where the travel warrant has been issued to. This email is automatically received by all offender managers within OMU. This information is then communicated to the Community Offender Manager and any other individuals/agencies involved with the prisoner.
• Whilst Community Offender Managers have responsibility for the coordination of release planning, notice was given by email to all offender managers within HMP & YOI Parc that they must notify the relevant Community Offender Manager when a prisoner is being released at sentence end date and will be of no fixed abode. When doing so, they must provide any information relating to a prisoner’s intentions in terms of where they are going on the day of release. This will assist the Community Offender Manager to effectively manage the prisoner’s release, and to coordinate and link in with other external agencies believed by the Community Offender Manager to be relevant to coordinate interagency working.
The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDelius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDelius, but information on this system is regularly accessible to Probation Service
4
Client Confidential staff working at HMP & YOI Parc, and Probation Service staff within the community. Any issues around sharing information recorded on NDelius should be addressed to HMPPS.
We trust this information is of assistance and provides reassurance regarding management of release from custody and interagency working to the extent that G4S is able to take action.
Jacob Michael Nicholas Billington
2
Client Confidential
4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
Response
G4S confines its response to the first concern identified relating to the management of release from prison and interagency working.
G4S has no power to take action regarding concerns 2, 3 and 4, and, therefore, is not in a position to assist HM Senior Coroner with regard to these concerns. Other interested persons to whom the Regulation 28 report has been addressed are better able to consider the concerns raised, take action and/or explain why no action is proposed.
In addition, G4S has no power to influence the management of release of prisoners from, and/or to ensure interagency working at, private prisons operated by other providers or HMPPS operated prisons.
Offender management in all prisons across England and Wales, including all privately operated prisons, is delivered pursuant to a HMPPS prescribed delivery model. Prisoners are case managed through their custodial sentence by a prison based Offender Management Unit (OMU) pursuant to the national Offender Management in Custody (OMiC) model, which provides a framework to coordinate and set out the sequence for a prisoner’s journey through custody to post-release. This model applies to all prisons in England and Wales.
Qualified probation officers and senior probation officers employed by the Probation Service/HMPPS are based at HMP & YOI Parc. All high-risk prisoners are managed by qualified Probation Service offender managers working at the prison.
HMPPS has responsibility for provision and operation of resettlement services. Such resettlement services at HMP & YOI Parc are commissioned by HMPPS from external providers who are based within the prison to facilitate resettlement services for prisoners approaching release from custody. G4S is not party to the procurement or placement of resettlement services within HMP & YOI Parc or the direct delivery of these services. G4S’ focus is on ensuring alignment and integration with third party service providers to ensure effective interagency working.
Resettlement services have responsibility for providing resettlement support to prisoners, including coordinating referrals and signposting to services such as housing and DWP benefits.
Responsibility for case management of any prisoner under the OMiC model passes to the Probation Service Community Offender Manager when a prisoner reaches a point which is eight and a half months prior to their release date. This includes responsibility for managing the prisoner’s release and coordinating liaison between relevant agencies involved and includes the sharing of information with all other relevant agencies and individuals working with the prisoner. The Community Offender Manager takes responsibility for coordinating the prisoner’s resettlement support, addressing and escalating any concerns relating to risk, and undertaking any required pre-release risk assessments, including OASys, a risk assessment conducted by the Community Offender Manager at various stages of the prisoner’s time in custody. Where a prisoner is recalled to custody their case management is the responsibility of the Probation Service Community Offender Manager with support from the prison based Prison Offender Manager.
3
Client Confidential Prior to release, the Community Offender Manager must review the OASys assessment and prepare a pre- release report/assessment of the prisoner using the OASys tool. This should place particular focus on resettlement needs and further actions required to safeguard against any concerns regarding potential risks of causing harm and/or of reoffending.
Further Action
Prior to conclusion of the inquest touching the death of Mr Billington, G4S had the opportunity to participate in and consider the outcomes of the NICHE report commissioned by the NHS, and a MAPPA serious case review, two detailed investigations into the material incident. No recommendations were made relating to G4S in respect of the discharge from prison in either of the reports, however, G4S carefully noted the findings and carefully noted evidence provided at the inquest touching the death of Mr Billington.
Having considered the two investigation reports and having listened to the evidence, steps have been taken by G4S at HMP & YOI Parc to reinforce information sharing and communication surrounding the release of a prisoner from custody.
• Resettlement services drop-in sessions have been introduced and approved laptops have been received from HMPPS to roll out remote sessions under resettlement activities, to encourage engagement with resettlement services by prisoners approaching release and to provide opportunities to gather further information.
• Monthly strategy meetings at the prison show consistently high (c 90%) levels of prisoners released from custody are housed on the first night of their release, so that their whereabouts immediately post release is known to relevant community services.
• At HMP & YOI Parc, a member of the cashiers team issues a travel warrant for each prisoner shortly before they are released from custody. The cashier previously recorded on CMS, the prison’s central electronic messaging system, the fact that a travel warrant had been issued. The cashier now records where the travel warrant has been issued to, and, in addition, sends an email to a new OMU email group, which includes healthcare admin and the Heads of Offender Management, to indicate that a travel warrant has been issued with details of where the travel warrant has been issued to. This email is automatically received by all offender managers within OMU. This information is then communicated to the Community Offender Manager and any other individuals/agencies involved with the prisoner.
• Whilst Community Offender Managers have responsibility for the coordination of release planning, notice was given by email to all offender managers within HMP & YOI Parc that they must notify the relevant Community Offender Manager when a prisoner is being released at sentence end date and will be of no fixed abode. When doing so, they must provide any information relating to a prisoner’s intentions in terms of where they are going on the day of release. This will assist the Community Offender Manager to effectively manage the prisoner’s release, and to coordinate and link in with other external agencies believed by the Community Offender Manager to be relevant to coordinate interagency working.
The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDelius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDelius, but information on this system is regularly accessible to Probation Service
4
Client Confidential staff working at HMP & YOI Parc, and Probation Service staff within the community. Any issues around sharing information recorded on NDelius should be addressed to HMPPS.
We trust this information is of assistance and provides reassurance regarding management of release from custody and interagency working to the extent that G4S is able to take action.
BSMHFT has revised the Standard Operating Procedure for the Prison Discharge Coordinator role and held an initial scoping meeting to address interagency working. They plan to include a MAPPA Clinical Lead, review the Prison Discharge Coordinator's job description, establish a working group for IT and communication, and have approached SystmOne to add CMHT details with a decision expected shortly.
AI summary
View full response
Dear Mrs Hunt, Re: Prevention of Future Deaths Jacob Billington Thank you for your Prevention of Future Death (PFD) report, which I understand has also been issued against the other Interested Parties within Mr Billington’s inquest. I would like to take this opportunity to offer my sincere condolences to Jacob’s family at this time and offer my assurances that as a trust we have carefully considered the issues that arose during the inquest and will use this time to ensure that lessons are learned for patients and the public in the future. In response to the following points: Management of release and lack of interagency working. Cross agency guidance regarding release of high-risk prisoners with mental health difficulties at their sentence end date. West Midlands MAPPA The Deputy Medical Director chaired an initial scoping meeting in response to these issues identified by the PFD on 10th April 2024, culminating in agreement on 3 primary areas of focus :
1. BSMHFT involvement in MAPPA. We acknowledge the need for a sustainable engagement strategy with the Multi-Agency Public Protection Arrangements (MAPPA). Currently the Prison Discharge Coordinator acts as the main link with the MAPPA process. There is a need to understand if this is sustainable and suitable. There is a plan to include the BSMHFT MAPPA Clinical Lead to support in outlining this and identifying any gaps to be alternatively planned for.
2. Role of the Prison Discharge Coordinator. The Standard Operating Procedure has been revised. In addition to this there is an intention to review the Job Description of this role and understand in more depth the scope of what this role can achieve currently or will need to achieve in the future including any potential additional resource requirements. This review is aimed at aligning the role's Legal Department B1 – Unit 1 50 Summer Hill Road Birmingham B1 3RB Tel:
capabilities with the evolving requirements of our service and ensuring it can effectively contribute to safer community reintegration
3. Interface between Prison In-reach and the CMHT- A comprehensive review of the current interaction process between the Prison In-reach team and the CMHT is planned. This will involve a detailed gap analysis to determine areas needing strengthening. We aim to develop a clear plan to enhance this interface, thereby improving continuity of care and ensuring that individuals receive the necessary support as they transition from prison to community-based services.
These workstreams are part of our ongoing commitment to make substantive, lasting changes that address the concerns raised. We understand the importance of ensuring these changes are not only implemented but are sustainable and lead to significant improvements in patient care and safety. We will continue to monitor the effectiveness of these changes closely and adjust our strategies as necessary to meet this commitment.
To ensure effective progress in addressing these areas, we will establish dedicated workstreams that will operate as part of a Task and Finish group. The stakeholders for each workstream will be responsible for reviewing existing processes and relevant policies to determine if further action is required. The initially identified stakeholders have been both cross-organisational and multi-professional including Secure Care Services, the In Reach Team, Community Mental Health Services (BSMHFT and FTB) and HMP Birmingham. As this work progresses, if additional key stakeholders are identified, they will be included.
Each workstream will formulate a plan, outlining specific outputs and associated timeframes. These plans will be overseen by the Deputy Medical Director for Quality and Safety and our Clinical Governance Committee.
Through this structured approach, we aim to thoroughly analyse, carefully plan and implement improvements where needed. Whilst we cannot give you an immediate outcome on these points, we will write formally and update you in 3 months on our progress.
In the meantime we can offer you assurances that since the events that culminated in Mr Billington’s death the Trust has improved the structure and supervision surrounding the prison discharge coordinator roles, such that the practitioners have weekly supervision with opportunity to escalate cases of concern, and an improved system of referrals and discharge procedures, reflected in the updated standard operating protocol. This means that in the event of a similar situation occurring again, there would be sufficient structure to ensure and support the flexibility in service provision to prevent such an individual falling between services, even where they had been discharged from active multiagency management by MAPPA.
In addition to our Prison Discharge Co-ordinator we also have our RECONNECT service in place which was not available previously. Whilst it is important to note our RECONNECT service is not a statutory service and engagement from service users is voluntary, their inclusion criteria is for prison leavers with low/medium risk profiles. They offer in reach support 12 weeks pre-release and then up to 6 months support post release in the community. RECONNECT is a vulnerability service supporting multiple service user needs including accessing mental health support.
They are based within HMP Birmingham however are a national service and accept referrals from Out of Area prisons for prison leavers relocating to Birmingham and Solihull. Additionally, prison leavers can be referred up to 28 days post release by probation offender managers, other professionals, family/friends or self-referrals.
In addition HMP Birmingham has an in-reach mental health team. If a prisoner is released who is on the mental health caseload, the team would refer into the local CMHT if not already
known to them. If they are already known to a community CMHT we would inform them of the release date and they would also be invited to any Care Programme Approach. If they are known to the Assertive Outreach Team or homeless team the team would also take this approach. If a prisoner is receiving a service from mental health in HMP Birmingham and is transferred to another jail the in-reach would inform the receiving jail and hand over any clinical information that is required. The in-reach team can also refer to RECONNECT service for prisoners who needs support in the community with mental health.
Systemone Whilst this point is an issue which will need to be addressed at a more national level by other Interested Parties, the Trust has also looked at its own Systemone interface in HMP Birmingham to see if this can be amended locally.
We are satisfied that GP details are readily recordable and accessible within the system. There is not currently a specific field for recording information by the community mental health team for those prisoners under the care of secondary mental health services. This is mitigated because NHS staff within the prison have access to the mental health records for people from Birmingham and Solihull however for prisoners from outside of the Birmingham area, the Trust may not have this access. Therefore an approach has been made to Systemone to discuss the feasibility of adding this to the system locally. We anticipate we will have a decision around this within the next month.
I fully appreciate your request for a detailed account of the changes we are implementing following the Prevention of Future Deaths report. I must emphasise that the nature of these changes is complex and inherently requires a strategic, phased approach to ensure they are sustainable and effectively address the issues identified. Significant improvements to practices and systems are not instantaneous but are developed over a considered period to ensure they are thoroughly embedded and genuinely effective. We are committed to making these improvements with the utmost diligence and oversight to prevent any future incidents and will keep all stakeholders updated as we progress.
If we can be of any further assistance at this time, please do contact us.
1. BSMHFT involvement in MAPPA. We acknowledge the need for a sustainable engagement strategy with the Multi-Agency Public Protection Arrangements (MAPPA). Currently the Prison Discharge Coordinator acts as the main link with the MAPPA process. There is a need to understand if this is sustainable and suitable. There is a plan to include the BSMHFT MAPPA Clinical Lead to support in outlining this and identifying any gaps to be alternatively planned for.
2. Role of the Prison Discharge Coordinator. The Standard Operating Procedure has been revised. In addition to this there is an intention to review the Job Description of this role and understand in more depth the scope of what this role can achieve currently or will need to achieve in the future including any potential additional resource requirements. This review is aimed at aligning the role's Legal Department B1 – Unit 1 50 Summer Hill Road Birmingham B1 3RB Tel:
capabilities with the evolving requirements of our service and ensuring it can effectively contribute to safer community reintegration
3. Interface between Prison In-reach and the CMHT- A comprehensive review of the current interaction process between the Prison In-reach team and the CMHT is planned. This will involve a detailed gap analysis to determine areas needing strengthening. We aim to develop a clear plan to enhance this interface, thereby improving continuity of care and ensuring that individuals receive the necessary support as they transition from prison to community-based services.
These workstreams are part of our ongoing commitment to make substantive, lasting changes that address the concerns raised. We understand the importance of ensuring these changes are not only implemented but are sustainable and lead to significant improvements in patient care and safety. We will continue to monitor the effectiveness of these changes closely and adjust our strategies as necessary to meet this commitment.
To ensure effective progress in addressing these areas, we will establish dedicated workstreams that will operate as part of a Task and Finish group. The stakeholders for each workstream will be responsible for reviewing existing processes and relevant policies to determine if further action is required. The initially identified stakeholders have been both cross-organisational and multi-professional including Secure Care Services, the In Reach Team, Community Mental Health Services (BSMHFT and FTB) and HMP Birmingham. As this work progresses, if additional key stakeholders are identified, they will be included.
Each workstream will formulate a plan, outlining specific outputs and associated timeframes. These plans will be overseen by the Deputy Medical Director for Quality and Safety and our Clinical Governance Committee.
Through this structured approach, we aim to thoroughly analyse, carefully plan and implement improvements where needed. Whilst we cannot give you an immediate outcome on these points, we will write formally and update you in 3 months on our progress.
In the meantime we can offer you assurances that since the events that culminated in Mr Billington’s death the Trust has improved the structure and supervision surrounding the prison discharge coordinator roles, such that the practitioners have weekly supervision with opportunity to escalate cases of concern, and an improved system of referrals and discharge procedures, reflected in the updated standard operating protocol. This means that in the event of a similar situation occurring again, there would be sufficient structure to ensure and support the flexibility in service provision to prevent such an individual falling between services, even where they had been discharged from active multiagency management by MAPPA.
In addition to our Prison Discharge Co-ordinator we also have our RECONNECT service in place which was not available previously. Whilst it is important to note our RECONNECT service is not a statutory service and engagement from service users is voluntary, their inclusion criteria is for prison leavers with low/medium risk profiles. They offer in reach support 12 weeks pre-release and then up to 6 months support post release in the community. RECONNECT is a vulnerability service supporting multiple service user needs including accessing mental health support.
They are based within HMP Birmingham however are a national service and accept referrals from Out of Area prisons for prison leavers relocating to Birmingham and Solihull. Additionally, prison leavers can be referred up to 28 days post release by probation offender managers, other professionals, family/friends or self-referrals.
In addition HMP Birmingham has an in-reach mental health team. If a prisoner is released who is on the mental health caseload, the team would refer into the local CMHT if not already
known to them. If they are already known to a community CMHT we would inform them of the release date and they would also be invited to any Care Programme Approach. If they are known to the Assertive Outreach Team or homeless team the team would also take this approach. If a prisoner is receiving a service from mental health in HMP Birmingham and is transferred to another jail the in-reach would inform the receiving jail and hand over any clinical information that is required. The in-reach team can also refer to RECONNECT service for prisoners who needs support in the community with mental health.
Systemone Whilst this point is an issue which will need to be addressed at a more national level by other Interested Parties, the Trust has also looked at its own Systemone interface in HMP Birmingham to see if this can be amended locally.
We are satisfied that GP details are readily recordable and accessible within the system. There is not currently a specific field for recording information by the community mental health team for those prisoners under the care of secondary mental health services. This is mitigated because NHS staff within the prison have access to the mental health records for people from Birmingham and Solihull however for prisoners from outside of the Birmingham area, the Trust may not have this access. Therefore an approach has been made to Systemone to discuss the feasibility of adding this to the system locally. We anticipate we will have a decision around this within the next month.
I fully appreciate your request for a detailed account of the changes we are implementing following the Prevention of Future Deaths report. I must emphasise that the nature of these changes is complex and inherently requires a strategic, phased approach to ensure they are sustainable and effectively address the issues identified. Significant improvements to practices and systems are not instantaneous but are developed over a considered period to ensure they are thoroughly embedded and genuinely effective. We are committed to making these improvements with the utmost diligence and oversight to prevent any future incidents and will keep all stakeholders updated as we progress.
If we can be of any further assistance at this time, please do contact us.
Swansea Bay University Health Board has established a comprehensive handover process for prisoner transfers and releases, and amended HMP Swansea's Mental Health In Reach electronic records to ensure GP and CMHT details are recorded at initial assessment. They have also alerted the MAPPA Coordinator to a concern about cross-agency guidance for high-risk prisoners.
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Dear Mrs Hunt,
RESPONSE BY SWASNEA BAY UNIVERISTY HEALTH BOARD TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS ISSUED IN THE INQUEST OF J BILLINGTON
Thank you for providing the Health Board with an opportunity to respond to your concerns raised at the conclusion of the inquest of Mr Jacob Billington.
At the outset I would wish to send my condolences on behalf of Swansea Bay University Health Board to Mr Billington’s family.
In your Prevention of Further Deaths notification, you identified the following concerns and stated that it was your opinion that there is a risk that future deaths will occur unless action is taken. The Report was addressed to 5 Interested Persons and I am responding on behalf of Swansea Bay University Health Board. In the following, I will seek to outline what action we have taken to address your concerns.
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 2
The MATTERS OF CONCERN identified were:
1. Management of release and lack of interagency working
The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning they are not traced and treated assertively in the community.
Response of Swansea Bay University Health Board
Swansea University Health Board recognise that there is not a shared database for interagency working in place across England and Wales prison establishments to enable the transfer and access to key information by agencies coordinating the discharge of high risk individuals.
Swansea Bay University Health Board were, at the time of Jacob Billington’s death, providing Mental Health In-Reach (MHIR) services within both HMP Parc and HMP Swansea. Since September 2023 the Health Board now only provide MHIR services to HMP Swansea.
Swansea Bay University Health Board does not have the power to implement a unified IT System but evidence was provided at the Inquest regarding the changes implemented by Swansea Bay University Health Board to include the steps taken to ensure that matters within their power to aid Care Coordination and discharge planning with the relevant agencies were established. Full details are set out below to ensure high risk, seriously unwell prisoners are not released without key agencies knowing where, and treated assertively in the community where appropriately identified.
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 3
The MHIR Team act as a provider of care whilst the individual is in custody and ensure:
• Formal hand over of care is received from the transferring Community Mental Health Team (CMHT) or previous prison via a formal meeting
• Formal pre-release meetings are held with CMHT or transferring prison
• Receive and review the Care and Treatment Plan (CTP) and Risk Assessment (RA) within 7 days of admission and upload onto the patient record (on SystemOne)
• Facilitate 6 monthly CTP review meetings
• Undertake CTP and RA monthly audits to ensure quality and performance
Prisoners in HMP Swansea, who will be predominantly Welsh, will be subject to the Mental Health Measure (Wales) 2012 and therefore will legally be required to have a Care and Treatment Plan – this will be continued to be overseen by the individual’s community Care Coordinator and the MHIR Team working in collaboration with them to ensure care provision within the custodial setting. Details of interventions conducted by the MHIR Team will be provided to the Care Coordinator as required or through the 6 monthly review meetings. In respect of MAPPA, Swansea Bay University Health Board undertake the role of a ‘Duty to Cooperate Agency’ with Probation, HMP and the Police as the Responsible Authority – it is the Responsible Authority’s responsibility to inform Health if a MAPPA eligible individual is scheduled for discharge and ensure we are invited to relevant meetings to coordinate release / discharge management. The MHIR Team liaise directly with the prison based Offender Management Unit and not directly with MAPPA. Liaison with MAPPA is the responsibility of the Offender Management Unit.
Discharge to Community The MHIR Team arrange a Multi-Disciplinary Team (MDT) review meeting prior to discharge. Discharge planning is individualised depending on the patient’s legal status (sentenced, or remand). When sentence end / release dates are known, MDT meetings are planned 4/6 weeks prior to identified date and these meetings are now designated as Formal Pre-Release Planning Meetings. A Formal discharge meeting is also held between the MHIR and Primary Care Teams when patients / prisoners within the prison setting are being discharged from secondary care services (MHIR) back to primary care services within the prison. This meeting includes a full
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 4
and comprehensive handover of care and a documented discharge summary. These meetings are recorded and documented. The MHIR CPN works with the prisoner / patient’s Care Co-ordinator by completing a recovery care plan and updating current risk assessment. If the prisoner / patient is already Care Co-ordinated within the community prior to incarceration then the MHIR Team become the co-workers, working alongside the patient’s Care Co-ordinator. This commences as soon as the prisoner / patient is allocated to MHIR team. The MHIR Team contact the Care Co- ordinator and request a joint meeting to update and undertake RA and care planning. We recognise that robust discharge planning is essential, particularly links with local mental health providers, GP’s and other interested parties. This is undertaken by:
• Formal pre-release meeting with CMHT / transferring prison / Probation and other agency involvement
• A discharge summary is completed and sent to the GP and given to the prisoner / patient - we issue the prisoner / patient with the discharge summary if they do not have a GP. With the prisoner / patient’s consent we also provide the discharge summary to their Probation Officer
• The MHIR Team make contact with the prisoner / patient 14 days following discharge and if there is no telephone number then we cannot do the follow up phone call. We do rely on other agencies such as Offender Managers for updates if there is no phone number. If the prisoner / patient has been transferred from MHIR to a hospital then the team follow up with the ward following the 14 day period
• On a weekly basis the MHIR Team are sent the discharge information of prisoners from the Offender Management Unit (OMU). We don’t request travel warrant information as the travel warrant is only issued on the day of travel. We also now have access to the prison NOMIS system which we didn’t previously (training for use is being rolled out to the whole team with 50% already achieved). This system is updated by the Resettlement Team and OMU regarding release dates. These layered approaches help to avoid the risk of the team not being aware of relevant information
• A Governor Grade officer now attends the MHIR Single Point of Access Meeting and they are able to log onto NOMIS and check the release date of each patient as they are being discussed, thus providing ‘live’ information to the meeting
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 5
Responsible Clinician role
• Clear documentation of capacity assessment surrounding treatment
• Attendance at S.117 (Mental Health Act) and CTP review meetings under the Mental Health Measure (Wales) requirements
Governance
• The development of the MHIR Audit plan ensures processes are in place to support and drive improvement
• The service specification document / operational policy have been updated which offers detail on the function of the MHIR service
• An action plan is now generated from SPAM with actions monitored and recorded and reviewed at subsequent meetings
• A MHIR Clinical Standards document has been developed covering the following domains:
1. Referral / Admission/ Assessment
2. Discharge / Transfer
3. Patient safety / experience
4. Training / Continuous Professional Development /Support
5. Workforce / Capacity
6. Medicines Management
7. Leadership and Governance
8. Partnership working
9. Environment
Audit findings are reported via:
• A Divisional report presented to the Mental Health & Learning Disability (MHLD) Quality and Safety Committee
• MHLD Performance Score Card
• HMP Swansea Partnership Board
• MHLD Clinical Audit Subgroup New additions to the Service Group performance score card:
• CTP / RA monthly audit via performance score card
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 6
• Handover of care data upon discharge (Discharge planning meetings)
• Number of release notification dates received from OMU
• Handover of care meetings upon admission
• 6 Monthly CTP Meetings
• Attendance at ACCT Meetings out of number of invites (weekly)
• CTP’s received from community Care Co-ordinator
• Number of patients not engaging with MHIR / action taken
• Number of patients declining medication / action taken
• Number of Did Not Attend by patients weekly in month / reason / action taken
• Number of cancelled clinics in month
There is also now improved partnership working with pharmacy regarding medication pathways and escalation of concerns in relation to non-compliance. Appropriate action is taken following review of circumstances of non-compliance.
2. SystemOne
Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. You were informed that this change in information management and presentation within SystemOne is unique to HMP Swansea and is not the practice in other prisons. You were concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
Response by Swansea Bay University Health Board
Swansea Bay University Health Board MHIR confirmed to the Coroner during the Inquest that they had implemented a change as detailed above within SystemOne - this was a local change. Swansea Bay University Health Board do not have the relevant system control to be able to implement a change to all SystemOne systems across the prison estates in England and Wales or to confirm what templates may already being used.
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The Health Board have made contact with Product Support Centre, Digital Health and Care Wales advising of the Coroners Regulation 28 Report. The Health Board will also report at National level to NHS Wales and Prison Health in Wales to take forward. The information included within this change allows direct access for local SystemOne users to identify the allocated MHIR worker, (if they are Care Coordinator / Co Worker or Assessor), whether they are known to or under a CMHT and have a Care Coordinator, their last known Registered GP (if known). These additions were made by the MHIR Team administrator and one of the MHIR CPN’s. These details are currently accessible to any Clinician working with / seeing the prisoner / patient at HMP Swansea only.
3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date.
There are no provisions available nor any cross agency guidance in place for when a high- risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
Response Swansea Bay University Health Board
Swansea Bay University Health Board have no jurisdiction/power over the actions required for this concern, but have alerted the MAPPA Coordinator to this concern and asked that it is raised at the local Strategic Management Board (SMB) for consideration – the Health Board are a ‘Duty to Cooperate Agency’ to these arrangements and will participate in SMB discussions.
4. West Midlands MAPPA
West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
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Response Swansea Bay University Health Board Swansea Bay University does not have power to take action regarding the concern detailed. I hope that you are assured from this response that the Health Board is taking appropriate measures within their power to address the issues that were identified during Mr Jacob Billington’s inquest.
RESPONSE BY SWASNEA BAY UNIVERISTY HEALTH BOARD TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS ISSUED IN THE INQUEST OF J BILLINGTON
Thank you for providing the Health Board with an opportunity to respond to your concerns raised at the conclusion of the inquest of Mr Jacob Billington.
At the outset I would wish to send my condolences on behalf of Swansea Bay University Health Board to Mr Billington’s family.
In your Prevention of Further Deaths notification, you identified the following concerns and stated that it was your opinion that there is a risk that future deaths will occur unless action is taken. The Report was addressed to 5 Interested Persons and I am responding on behalf of Swansea Bay University Health Board. In the following, I will seek to outline what action we have taken to address your concerns.
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 2
The MATTERS OF CONCERN identified were:
1. Management of release and lack of interagency working
The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning they are not traced and treated assertively in the community.
Response of Swansea Bay University Health Board
Swansea University Health Board recognise that there is not a shared database for interagency working in place across England and Wales prison establishments to enable the transfer and access to key information by agencies coordinating the discharge of high risk individuals.
Swansea Bay University Health Board were, at the time of Jacob Billington’s death, providing Mental Health In-Reach (MHIR) services within both HMP Parc and HMP Swansea. Since September 2023 the Health Board now only provide MHIR services to HMP Swansea.
Swansea Bay University Health Board does not have the power to implement a unified IT System but evidence was provided at the Inquest regarding the changes implemented by Swansea Bay University Health Board to include the steps taken to ensure that matters within their power to aid Care Coordination and discharge planning with the relevant agencies were established. Full details are set out below to ensure high risk, seriously unwell prisoners are not released without key agencies knowing where, and treated assertively in the community where appropriately identified.
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 3
The MHIR Team act as a provider of care whilst the individual is in custody and ensure:
• Formal hand over of care is received from the transferring Community Mental Health Team (CMHT) or previous prison via a formal meeting
• Formal pre-release meetings are held with CMHT or transferring prison
• Receive and review the Care and Treatment Plan (CTP) and Risk Assessment (RA) within 7 days of admission and upload onto the patient record (on SystemOne)
• Facilitate 6 monthly CTP review meetings
• Undertake CTP and RA monthly audits to ensure quality and performance
Prisoners in HMP Swansea, who will be predominantly Welsh, will be subject to the Mental Health Measure (Wales) 2012 and therefore will legally be required to have a Care and Treatment Plan – this will be continued to be overseen by the individual’s community Care Coordinator and the MHIR Team working in collaboration with them to ensure care provision within the custodial setting. Details of interventions conducted by the MHIR Team will be provided to the Care Coordinator as required or through the 6 monthly review meetings. In respect of MAPPA, Swansea Bay University Health Board undertake the role of a ‘Duty to Cooperate Agency’ with Probation, HMP and the Police as the Responsible Authority – it is the Responsible Authority’s responsibility to inform Health if a MAPPA eligible individual is scheduled for discharge and ensure we are invited to relevant meetings to coordinate release / discharge management. The MHIR Team liaise directly with the prison based Offender Management Unit and not directly with MAPPA. Liaison with MAPPA is the responsibility of the Offender Management Unit.
Discharge to Community The MHIR Team arrange a Multi-Disciplinary Team (MDT) review meeting prior to discharge. Discharge planning is individualised depending on the patient’s legal status (sentenced, or remand). When sentence end / release dates are known, MDT meetings are planned 4/6 weeks prior to identified date and these meetings are now designated as Formal Pre-Release Planning Meetings. A Formal discharge meeting is also held between the MHIR and Primary Care Teams when patients / prisoners within the prison setting are being discharged from secondary care services (MHIR) back to primary care services within the prison. This meeting includes a full
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 4
and comprehensive handover of care and a documented discharge summary. These meetings are recorded and documented. The MHIR CPN works with the prisoner / patient’s Care Co-ordinator by completing a recovery care plan and updating current risk assessment. If the prisoner / patient is already Care Co-ordinated within the community prior to incarceration then the MHIR Team become the co-workers, working alongside the patient’s Care Co-ordinator. This commences as soon as the prisoner / patient is allocated to MHIR team. The MHIR Team contact the Care Co- ordinator and request a joint meeting to update and undertake RA and care planning. We recognise that robust discharge planning is essential, particularly links with local mental health providers, GP’s and other interested parties. This is undertaken by:
• Formal pre-release meeting with CMHT / transferring prison / Probation and other agency involvement
• A discharge summary is completed and sent to the GP and given to the prisoner / patient - we issue the prisoner / patient with the discharge summary if they do not have a GP. With the prisoner / patient’s consent we also provide the discharge summary to their Probation Officer
• The MHIR Team make contact with the prisoner / patient 14 days following discharge and if there is no telephone number then we cannot do the follow up phone call. We do rely on other agencies such as Offender Managers for updates if there is no phone number. If the prisoner / patient has been transferred from MHIR to a hospital then the team follow up with the ward following the 14 day period
• On a weekly basis the MHIR Team are sent the discharge information of prisoners from the Offender Management Unit (OMU). We don’t request travel warrant information as the travel warrant is only issued on the day of travel. We also now have access to the prison NOMIS system which we didn’t previously (training for use is being rolled out to the whole team with 50% already achieved). This system is updated by the Resettlement Team and OMU regarding release dates. These layered approaches help to avoid the risk of the team not being aware of relevant information
• A Governor Grade officer now attends the MHIR Single Point of Access Meeting and they are able to log onto NOMIS and check the release date of each patient as they are being discussed, thus providing ‘live’ information to the meeting
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 5
Responsible Clinician role
• Clear documentation of capacity assessment surrounding treatment
• Attendance at S.117 (Mental Health Act) and CTP review meetings under the Mental Health Measure (Wales) requirements
Governance
• The development of the MHIR Audit plan ensures processes are in place to support and drive improvement
• The service specification document / operational policy have been updated which offers detail on the function of the MHIR service
• An action plan is now generated from SPAM with actions monitored and recorded and reviewed at subsequent meetings
• A MHIR Clinical Standards document has been developed covering the following domains:
1. Referral / Admission/ Assessment
2. Discharge / Transfer
3. Patient safety / experience
4. Training / Continuous Professional Development /Support
5. Workforce / Capacity
6. Medicines Management
7. Leadership and Governance
8. Partnership working
9. Environment
Audit findings are reported via:
• A Divisional report presented to the Mental Health & Learning Disability (MHLD) Quality and Safety Committee
• MHLD Performance Score Card
• HMP Swansea Partnership Board
• MHLD Clinical Audit Subgroup New additions to the Service Group performance score card:
• CTP / RA monthly audit via performance score card
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 6
• Handover of care data upon discharge (Discharge planning meetings)
• Number of release notification dates received from OMU
• Handover of care meetings upon admission
• 6 Monthly CTP Meetings
• Attendance at ACCT Meetings out of number of invites (weekly)
• CTP’s received from community Care Co-ordinator
• Number of patients not engaging with MHIR / action taken
• Number of patients declining medication / action taken
• Number of Did Not Attend by patients weekly in month / reason / action taken
• Number of cancelled clinics in month
There is also now improved partnership working with pharmacy regarding medication pathways and escalation of concerns in relation to non-compliance. Appropriate action is taken following review of circumstances of non-compliance.
2. SystemOne
Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. You were informed that this change in information management and presentation within SystemOne is unique to HMP Swansea and is not the practice in other prisons. You were concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
Response by Swansea Bay University Health Board
Swansea Bay University Health Board MHIR confirmed to the Coroner during the Inquest that they had implemented a change as detailed above within SystemOne - this was a local change. Swansea Bay University Health Board do not have the relevant system control to be able to implement a change to all SystemOne systems across the prison estates in England and Wales or to confirm what templates may already being used.
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The Health Board have made contact with Product Support Centre, Digital Health and Care Wales advising of the Coroners Regulation 28 Report. The Health Board will also report at National level to NHS Wales and Prison Health in Wales to take forward. The information included within this change allows direct access for local SystemOne users to identify the allocated MHIR worker, (if they are Care Coordinator / Co Worker or Assessor), whether they are known to or under a CMHT and have a Care Coordinator, their last known Registered GP (if known). These additions were made by the MHIR Team administrator and one of the MHIR CPN’s. These details are currently accessible to any Clinician working with / seeing the prisoner / patient at HMP Swansea only.
3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date.
There are no provisions available nor any cross agency guidance in place for when a high- risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
Response Swansea Bay University Health Board
Swansea Bay University Health Board have no jurisdiction/power over the actions required for this concern, but have alerted the MAPPA Coordinator to this concern and asked that it is raised at the local Strategic Management Board (SMB) for consideration – the Health Board are a ‘Duty to Cooperate Agency’ to these arrangements and will participate in SMB discussions.
4. West Midlands MAPPA
West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
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Response Swansea Bay University Health Board Swansea Bay University does not have power to take action regarding the concern detailed. I hope that you are assured from this response that the Health Board is taking appropriate measures within their power to address the issues that were identified during Mr Jacob Billington’s inquest.
HMPPS has promoted the NHS-England Reconnect Service to practitioners to improve support for prisoners transitioning to the community and shared learning from the death. They also committed to supporting revisions to the Prison Discharge Coordinator role guidance.
AI summary
View full response
Dear Mrs. Hunt, Inquest into the death of Jacob Michael Nicholas Billington Thank you for your Regulation 28 Report, issued following the Inquest into the death of Jacob Billington addressed to HMPPS (His Majesty’s Prison and Probation Service). I am the Regional Probation Director for West Midlands Probation and am replying on behalf of HMPPS. I know that you will share a copy of this response with the family and I would first like to express my sincere condolences for their loss. You have raised the following areas of concerns to which I respond as follows:-
1.Management of release and lack of interagency working The management of the perpetrator’s release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of
2 future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning they are not traced and treated assertively in the community. For a prisoner to still be detained in custody at the point of sentence expiry is usually as a result of them having being recalled to custody. This means they remain the responsibility of the Probation Community Offender Manager (COM) until the point of release at the sentence end date (SED). There is no statutory authority for Probation supervision of a prisoner released into the community at SED. The sharing of information prior to release into the community in an effective manner with relevant agencies is therefore of paramount importance. The Probation Service West Midlands has a practice document which sets out the expectations for Practitioners when cases are being released at SED. This document has been revised and re issued to all staff and embedded in development sessions delivered by the Regional Quality Team. The processes to be followed prior to release include completion of a termination OASys (offender assessment) risk assessment which will identify the areas of risk which require the sharing of information with other agencies and, if applicable, under Multi Agency Public Protection (MAPPA) arrangements. MAPP arrangements are overseen by a Strategic Management Board (SMB) and in the West Midlands this Board will continue to review and refine practices to ensure interagency working is effective and to support the sharing of relevant risk information. The findings in this case have been presented to MAPPA SMB. The SMB is committed to ensuring their part in providing avenues to share information. Furthermore, the SMB has reinforced the statutory requirement for all duty to cooperate agencies in the MAPPA arena.
2. Systmone Systmone is an IT system used by healthcare professionals, and is not a system that HMPPS can access, review or change.
3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community. NHS-England are commissioned to provide healthcare in Prisons. The sharing of information between health in custody and health in the community is a core feature of the nationally rolled out NHS-England Reconnect Service. West Midlands Probation Service has actively promoted the Reconnect Service with Probation Practitioners in recent months to ensure they are aware of how to refer into this service in Prison for support “through the gate”, the transition period from prison into the community.
4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
3 The Prison Discharge Coordinator role is a Health Trust bespoke role in Birmingham and Solihull. West Midlands Probation Service welcomes the investment in this role for this area and will work with the Health Trust to support any Guidance revisions undertaken by the Health Trust to ensure that the Guidance is clear and enables effective information sharing and can be embedded within and understood by all in the Probation Service. Thank you for bringing these matters of concern to my attention. Please be assured that since I attended Jacob’s inquest, learning from the circumstances of this tragic death has been shared more widely with colleagues and will continue to inform improvements across all the Probation Regions.
1.Management of release and lack of interagency working The management of the perpetrator’s release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of
2 future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning they are not traced and treated assertively in the community. For a prisoner to still be detained in custody at the point of sentence expiry is usually as a result of them having being recalled to custody. This means they remain the responsibility of the Probation Community Offender Manager (COM) until the point of release at the sentence end date (SED). There is no statutory authority for Probation supervision of a prisoner released into the community at SED. The sharing of information prior to release into the community in an effective manner with relevant agencies is therefore of paramount importance. The Probation Service West Midlands has a practice document which sets out the expectations for Practitioners when cases are being released at SED. This document has been revised and re issued to all staff and embedded in development sessions delivered by the Regional Quality Team. The processes to be followed prior to release include completion of a termination OASys (offender assessment) risk assessment which will identify the areas of risk which require the sharing of information with other agencies and, if applicable, under Multi Agency Public Protection (MAPPA) arrangements. MAPP arrangements are overseen by a Strategic Management Board (SMB) and in the West Midlands this Board will continue to review and refine practices to ensure interagency working is effective and to support the sharing of relevant risk information. The findings in this case have been presented to MAPPA SMB. The SMB is committed to ensuring their part in providing avenues to share information. Furthermore, the SMB has reinforced the statutory requirement for all duty to cooperate agencies in the MAPPA arena.
2. Systmone Systmone is an IT system used by healthcare professionals, and is not a system that HMPPS can access, review or change.
3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community. NHS-England are commissioned to provide healthcare in Prisons. The sharing of information between health in custody and health in the community is a core feature of the nationally rolled out NHS-England Reconnect Service. West Midlands Probation Service has actively promoted the Reconnect Service with Probation Practitioners in recent months to ensure they are aware of how to refer into this service in Prison for support “through the gate”, the transition period from prison into the community.
4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
3 The Prison Discharge Coordinator role is a Health Trust bespoke role in Birmingham and Solihull. West Midlands Probation Service welcomes the investment in this role for this area and will work with the Health Trust to support any Guidance revisions undertaken by the Health Trust to ensure that the Guidance is clear and enables effective information sharing and can be embedded within and understood by all in the Probation Service. Thank you for bringing these matters of concern to my attention. Please be assured that since I attended Jacob’s inquest, learning from the circumstances of this tragic death has been shared more widely with colleagues and will continue to inform improvements across all the Probation Regions.
Report Sections
Investigation and Inquest
On 9 September 2020 I commenced an investigation into the death of Jacob Michael Nicholas BILLINGTON. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Unlawfully killed
Circumstances of the Death
Jacob was unlawfully killed when he was stabbed in the neck on 06/09/20 whilst on a night out in Birmingham with friends. A number of other people were also seriously injured that night by the same perpetrator over a 90 minute period. At the time of the attack the perpetrator was suffering from paranoid schizophrenia a severe and enduring mental illness which was characterised by him constantly hearing voices which at times told him to harm others including 'kill em stab em'. The perpetrator had not been receiving regular prescribed anti-psychotic medication in the months leading up to attack and he also may have taken illicit drugs, both of which may have contributed to the deterioration his mental state. On 22 April 2020 the perpetrator had been released from prison at the end of a three year sentence for drug and firearm offences. He had a long history of violent offending and was known to be a high risk of harm to the public and to have sporadic compliance with anti-psychotic medication, but there was no lawfully available control that might have been placed upon on him at the end of his sentence to protect the public from the recognised high risk he presented. The perpetrator had a long history of refusing to engage with agencies whilst in prison. Although he had been in the community on licence under MAPPA (Multi Agency Public Protection Arrangements) he was recalled to prison on 24/12/18. Shortly after his transfer to HMP Parc on 12/9/19 the MAPPA oversight was prematurely ended without any plan in place aimed at ensuring a co-ordinated release from prison and some of the actions that were prescribed by MAPPA relating to liaison with his local CMHT were not completed. The MAPPA process did not effectively promote risk reduction as it discharged him without plans being in place for a coordinated approach to the care of the perpetrator in prison or to ensure interagency planning for his release. The secondary mental health services In Reach team at HMP Parc failed to conduct a risk assessment or devise any care plan or risk management plan, and there was an absence of adequate coordination between all the numerous agencies involved with him in respect of resettlement and release planning. It was known by 10 March 2020 that a requested resettlement in Wrexham was not going ahead and on 3 April 2020 that he was returning to Birmingham with no fixed address. This was not communicated to the relevant agencies including the Birmingham CMHT. On release on 22 April 2020 the perpetrator requested a travel warrant to Birmingham where he lived until the events of 06 September 2020 which was also not communicated. He was released without any support in place for his serious mental illness. By the time the Birmingham CMHT identified in June 2020 where he had moved to on leaving prison he had recently changed address and establishing his whereabouts was not pursued by the CMHT until after he had presented to a new GP on 10th August 2020 asking to be prescribed anti-psychotic medication and after a new care coordinator was in place. He was then seen, on the doorstep of his home on 03 September 2020 by a CPN when he declined to attend a pre-arranged appointment with the CMHT consultant psychiatrist who already knew him from an assessment undertaken in December 2018, but he did agree to have a short telephone conversation with that psychiatrist. A limited assessment was undertaken and it was reasonably planned to instruct the GP to restart him on medication and to review him in the clinic in several weeks' time. It is not known whether he received or took any medication. Three days later the perpetrator attacked several wholly innocent members of the public in Birmingham City Centre and it was during these attacks that Jacob was killed. The failure to adequately manage his release to Birmingham and the failure to ensure the CMHT were notified of his release resulted in a lost opportunity to assertively manage his serious mental health condition and this possibly contributed to his mental state on 06/09/20. Whilst it cannot be said that he probably would have then complied with treatment offered for his significant mental health needs there is a realistic possibility that he would have done so. Following a post mortem/Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1a SHARP FORCE NECK TRAUMA 1b 1c II
Copies Sent To
3. Shropshire Community Health NHS Trust the MHIT
4. Forward Thinking Birmingham
5. , through his solicitors the Medical Examiner, ICS, NHS England, CQC
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.