Dear Mr Reid RE: Andrew Paul Shirley (deceased) Report to Prevent Future Deaths Thank you for your letter dated 27th January 2023, reporting a matter to us, in accordance with Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. May I take this opportunity to reassure you that following Mr Shirley’s death, we undertook a thorough investigation into the care delivered by the Midlands Partnership Foundation Trust. MATTER OF CONCERN: The three areas of concern were;
1. You heard evidence that, following concerns raised in the inquest about failures by the mental healthcare staff at the prison to complete documentation in a timely fashion or, (on occasions) at all, a “rigorous” 2 day training package for all mental healthcare staff at the prison has now been implemented. However, as at
20.01.2023 no data could be provided which showed how many of the current mental healthcare staff at the prison had actually received this training.
2. You heard evidence that v.6 of the ACCT document had been in place at prisons throughout England and Wales since June 2021, and that training relevant thereto consists of; Together we are making life better for our communities

i) ACCT v6 training; and ii) SASH (suicide and self-harm) model 3 training However, you also heard that, as at 20.01.2023 (over 18 months after the introduction of the latest ACCT document): a) 42% of mental healthcare staff at the prison had not received the ACCT v6 training (but would be receiving it that very day); and b) SASH training for all mental healthcare staff had been booked for February and March 2023. It is of considerable concern that such a high percentage of mental healthcare staff at the prison may not be in a position to recognise the risk which a prisoner presents of suicide and/or self-harm, and therefore to take the appropriate steps to reduce that risk.
3. You also heard evidence that, despite the introduction of a new Initial Segregation Health Screen Algorithm document for prisoners in the Segregation Unit, there has been no training for mental healthcare staff in how to complete these documents appropriately; and It is of particular concern that members of the mental healthcare staff at the prison are expected to have active involvement in the completion of these important documents, which aim to identify prisoners who may be at risk of suicide and/or self-harm if placed in the Segregation Unit, without any suitable training to qualify them to do so. Following discussions within the mental health services in the Specialist Services Care Group and with corporate services, I am now in a position to respond to the specific concerns raised during the course of the inquest.
4. You heard evidence that, following concerns raised in the inquest about failures by the mental healthcare staff at the prison to complete documentation in a timely fashion or, (on occasions) at all, a “rigorous” 2 day training package for all mental healthcare staff at the prison has now been implemented. However, as at 20.01.2023 no data could be provided which showed how many of the current mental healthcare staff at the prison had actually received this training. MPFT take the issue of record keeping very seriously. To support our Prison staff we provide a range of learning opportunities delivered in a variety of ways. Record keeping is included as a mandatory element within our Trust Induction during which new staff have to complete an online Data Security Awareness training module which covers Information Governance and General Data Protection Regulations (GDPR). The Trust Induction will be completed within the first 4 weeks. This is currently at 91% compliance for HMP Hewell, with outstanding training to be completed to achieve 100% by 31st March 2023. As part of the local Induction all new staff are given instruction on how to use SystmOne and what would be expected in regard to record keeping standards. These are detailed in 2

the Inclusion Prisons Good Practice Guide. We have now introduced processes to ensure that the local induction will be completed within the first four weeks of commencement. Inclusion have developed a competency based local induction in which Team managers will sign off staff as competent to practice. Agency nurses complete the same Induction process as permanent staff. There is a Prison specific record keeping training provided for all staff on an annual basis. We will video record this session so it can be made available to people to watch as part of their induction pending completing the course face to face. Topics covered in this training include:  The importance of keeping good health records.  The requirement to record contacts contemporaneously  The requirement to gather relevant information from other parties involved in their care.  Making a clinical formulation which directs decision making  Informed consent  Care coordination – roles and responsibilities  MPFT Risk Management processes The most recent training was delivered in June 2022 at which point we were 100% compliant. Due to staff turnover compliance is currently at 67%. Therefore a further record keeping training session has been planned for 25th April 2023 at which point 100% of all our staff will have completed the Prison Specific Record Keeping training. Attendance at the training will be recorded and monitored locally. Any new staff will view the recording of the training as part of their induction pending attending a face to face session. At the next training we will be using Mr Shirley’s case as a case study to demonstrate the importance of good record keeping. During supervision sessions we review two random case records to ensure that these meet the expected standards of record keeping. In cases where the records don’t meet expected standards an improvement plan will be developed with the individual. Supervision occurs at least 6 times a year. This is inclusive of agency staff. Where there are performance issues the frequency will be increased to monthly. As part of our mandatory training compliance process, service leaders receive monthly monitoring reports detailing current compliance in regard to supervision. If necessary this can also be checked on the live system.
5. You heard evidence that v.6 of the ACCT document had been in place at prisons throughout England and Wales since June 2021, and that training relevant thereto consists of; iii) ACCT v6 training; and iv) SASH (suicide and self-harm) model 3 training 3

However, you also heard that, as at 20.01.2023 (over 18 months after the introduction of the latest ACCT document): a) 42% of mental healthcare staff at the prison had not received the ACCT v6 training (but would be receiving it that very day); and b) SASH training for all mental healthcare staff had been booked for February and March 2023. It is of considerable concern that such a high percentage of mental healthcare staff at the prison may not be in a position to recognise the risk which a prisoner presents of suicide and/or self-harm, and therefore to take the appropriate steps to reduce that risk. ACCT training is provided by the Prison and it is expected that all MPFT Prison staff attend this training as part of their Induction. Attendance at ACCT training is recorded and monitored locally. An understanding of the ACCT process is part of the Inclusion Prison Induction and needs to be signed off by a manager/supervisor. As well as attendance at the training all MPFT staff are given a copy of the Inclusion Good Practice Guide to working in Prisons which includes information on ACCT processes. The use and function of the ACCT process is discussed in internal team meetings, MPCCC meetings and in specific ACCT meetings so new staff get the chance to familiarise themselves with how an ACCT is used. As at March 2023 Mental Healthcare staff at HMP Hewell are 100% compliant with ACCT training. Suicide and Self harm Training Clinical Risk Management Training is one of MPFT’s mandatory training standards. This includes the identification and management of suicidality. As at March 2023 staff at HMP Hewell were 84% compliant with a plan to achieve 100% compliance by the end of March. In February 2023 MPFT launched a three level Suicide Mitigation Training which is detailed below. This will be part of the Prison Induction process and will be in place of the current two day training module. Training LEVEL 1 Zero Suicide Alliance ESR Course Name 000 MPFT Zero Suicide Alliance Awareness (Level 1) Who For All MPFT Staff Delivery Method E- Learning Duration 30 Minutes Course Aims To raise awareness of suicide prevention and mitigation LEVEL 2 Suicide 301 Suicide Awareness All Clinical Non MS Teams 2 Hours To increase understanding 4

Awareness for Professionals for Professionals (Level 2) Registered & Registered Practitioners in ALL fields of practice and compassion and reduce the stigma associated with talking about suicide. LEVEL 3 301 Suicide All MS 1 Day To provide Suicide Response Registered Teams clinical tools to Response (Level 3) Practitioners enhance the Part 1 & 2 working in Mental Health & Learning Disability fields processes of suicide assessment and promote common language to improve prioritisation and referrals. Completing all three levels will be essential for all registered Clinical Prison staff and will be monitored via our Electronic Staff Record (ESR). 100% Mental Health staff have completed level 1 training and level 2 and 3 are booked to take place in June/July 2023. Staff continue to have access to the Inclusion Suicide Prevention and Awareness Toolkit. A HMP Hewell suicide prevention strategy is being developed as a partnership approach which includes the Prison, PPG, MPFT as well as other partner agencies such as education and Chaplaincy services.
6. You also heard evidence that, despite the introduction of a new Initial Segregation Health Screen Algorithm document for prisoners in the Segregation Unit, there has been no training for mental healthcare staff in how to complete these documents appropriately; and It is of particular concern that members of the mental healthcare staff at the prison are expected to have active involvement in the completion of these important documents, which aim to identify prisoners who may be at risk of suicide and/or self-harm if placed in the Segregation Unit, without any suitable training to qualify them to do so. Health Screen Algorithm training is provided to MPFT staff by PPG. This is now in place and all registered nurses at HMP Hewell, inclusive of agency nurses, had completed the training by 3 February 2023. A new member of staff who started 2 weeks ago is the only member of staff not to have completed this but will do as part of their induction. This is part of the required training for staff working in prisons and is provided as part of and will monitored within our Induction process. We are in dialogue with PPG about how we can get our staff trained to also deliver this training. 5

While Segregation Health Screening is the responsibility of PPG, MPFT mental health staff will support this process and, where appropriate, contribute to the completion and review of the algorithm. All new staff will shadow an experienced member of staff supporting the completion of the Algorithm prior to doing so on their own. I hope this response helps to address your concerns. However, if you require any further information please do not hesitate to contact me.

Dear Sir Regulation 28: Prevention of Future Deaths Report – Andrew Shirley I write in response to your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus Group on 27 January 2023 following the inquest touching upon the death of Mr Andrew Shirley at HMP Hewell. Practice Plus Group would like to express its sincere condolences to Mr Shirley’s family and friends. This response addresses the matters of concern in so far as they relate to Practice Plus Group Health & Rehabilitation Limited (“Practice Plus Group”), the lead provider of healthcare services at HMP Hewell since 1 April 2016. Matter of Concern: A high percentage of healthcare staff at the prison may not be in a position to recognise the risk which a prisoner presents of suicide and/or self-harm, and therefore to take appropriate steps to reduce that risk (due to not having received ACCT training). Response: The ACCT process is governed by the prison and to date Practice Plus Group have been reliant upon the prison to run the training required. Training on ACCT and SASH (suicide and self-harm) are done together as part of the same sessions. In a new joint collaborative initiative between our prison colleagues, Practice Plus Group and the Midlands Partnership NHS Foundation Trust (MPFT), a cohort of healthcare staff have been identified to be trained to deliver the ACCT training. This will significantly improve our ability to Practice Plus Group Health and Rehabilitation Services Ltd. Registered in England No 10498997 Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW

ensure training for our workforce as it enables Practice Plus Group and MPFT to train our staff on the ACCT process without the current reliance upon the prison. Following a recent period of focused training activity, including a training session on 9 March 2023, compliance for ACCT training for the healthcare team at HMP Hewell is now 76.8%. Our aim is to have all staff at HMP Hewell trained by the end of April. In addition to the above, and to provide further assurance, Practice Plus Group’s Health in Justice service has identified clinical induction as one of its three top corporate priorities this year. A new national clinical induction is being developed, which will incorporate foundation training in the ACCT process, ensuring that all staff receive this prior to commencing work in prison. This will serve as an introduction to the full ACCT training, which will be delivered within the first six months of employment, once our healthcare professionals have acquired practical and contextual experience to support this. It is intended that the Clinical Induction will have an implementation date of no later than 1 October 2023. There are no requirements or national standards in regards to ACCT and SASH refresher training. However, to further embed understanding of the ACCT process, Practice Plus Group will introduce a refresher training session to be completed at 2 yearly intervals following completion of initial training. This will be monitored on an ongoing basis via our organisational Learning Management System (LMS). Matter of Concern: Members of healthcare staff at the prison may be completing a document which aims to identify prisoners who may be at risk of suicide and/or self-harm if placed in the Segregation Unit, without any suitable training to qualify them to do so. Response: As part of the revision of Prison Service Order 1700 (Segregation) in June 2022, a new Initial Segregation Health Screen (ISHS) algorithm document for prisoners in the Segregation Unit was introduced. It is Practice Plus Group’s understanding that previously no healthcare provider within the Health in Justice estate has provided specific training to staff around the completion of the algorithm document. In correspondence with , Head of Healthcare at HMP Hewell, (Segregation Policy Lead for HMPPS) has confirmed that there is “no centrally provided training available to healthcare staff on the completion of the OT014”. OT014 is the Initial Segregation Health screen algorithm document.

Practice Plus Group has taken immediate action to address this concern and our Director of Nursing & Quality has developed a comprehensive training session. The training incorporates an overview of the prison processes for segregation, clinical assessment (utilising ISHS and other available information to support decision making) and professional accountability. The session includes a knowledge-based test and scenario-based learning. The training session and associated resources are enclosed to support this response. The training was delivered at HMP Hewell on 25 and 26 January 2023 and was attended by , Regional Primary Care Lead, to enable her to deliver the same training face- to-face across the region. Training compliance at HMP Hewell is currently 88%, and further dates have been arranged to ensure full compliance by 31 March 2023. Our Director of Nursing & Quality and the Head of Healthcare at HMP Hewell are currently liaising with the governor of the prison ( ) to ensure that the training is delivered as a collaborative initiative between prison and healthcare colleagues. We aim to promote shared understanding of the risks associated with segregation, and the requirement for joint care planning to ensure appropriate care for those who are segregated. We also intend to share this work more widely through prison and healthcare networks to encourage shared learning for safer segregation. I hope that the above response provides assurance that Practice Plus Group are committed to providing a high quality healthcare service at HMP Hewell and trust this response addresses the concerns you had. I would like to end this response by taking the opportunity of inviting you to visit the healthcare team at HMP Hewell should you wish to discuss and review first-hand the services that Practice Plus Group provide, as set out in this letter.

Dear Mr Reid,

Thank you for your Regulation 28 report of 27 January 2023, addressed to the Governor of HMP Hewell. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.

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

You have expressed concerns regarding the number of staff that have not yet received the updated Assessment, Care in Custody and Teamwork (ACCT) version 6 (v6) and Suicide and Self-Harm Prevention (SASH) training.

It is essential that ACCT procedures are utilised by all members of staff working within prisons, including healthcare colleagues, and that staff feel confident in recognising risk and in making the decision to open an ACCT in order to support prisoners when it is needed. ACCT v6 and SASH training includes guidance on understanding and assessing the risks and triggers of self-harm, the ACCT v6 process and supporting individuals who self-harm while they are under ACCT monitoring and during the post closure period. HMP Hewell is currently delivering training sessions that incorporate both ACCT v6 and SASH training to all staff with the expectation that this will be completed by July 2023.

You were also concerned that Duty Governors had not yet received any training about the steps they should take in order to complete the Initial Segregation Health Screen algorithm document for prisoners in the Segregation Unit.

HMP Hewell has developed Duty Governor guidance for managing the risk of segregation and delivered a training session to all Duty Governors in March 2023. The training included information on the policy requirements, how to review periods of increased risk and the process of the Initial Segregation Health Screen.

Since Mr Shirley’s death, a number of supporting tools have also been published by HMPPS to assist prisons in ensuring segregation is managed appropriately. This has included a learning guide on how to effectively collate, analyse and share data to enhance local decision-making and multidisciplinary practice.

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