Dear Sir Mathew Colin Sargent (deceased) Regulatlon 28: Report to prevent future deaths: am writing in response t0 your letter of 7 April 2O16 addressed to Worcester Health and Care NHS Trust, This has been passed to Care UK a5 the new provider of healthcare services at HMP Long Lartin with effect from 1 April 2016, have noted the Matters of Concern which you Identified in section 5 ofyour report and respond 35 follows: 1 The Personol Officer of Mr Sargert appeared to have had little to do with him. It was suggested thof there should be regular meetings Between Personal Officers ard individual prisoners s0 that more in depth knowledge of individuol prisoners could be obtoined ond shared; The role and responsibilities of Personal Officers fall within the remit of the Prison Service and not the Healthcare Provider, Care UK is therefore Unable t0 comment an this kut trusts that the Government Legal Depattment wIll respond on behalfafthe MoJ_
2) There Wo; concem thot historicol information wnlch Wos ovollable t0 Offcers and Heolthcore Stoff wos rot revlewed when the prisoner first presented ot the prison ond it wos suggested that ir would be beneficial 4 there wos 0n Inslruction thot Ary member of stoff dealing wlth 0 prisoner who hod gccess t0 historicol information should moke sorg erquiry 0s [0 that hlstoricol Infarmatlom 59 Gs t0 inform them Of both the present ond post risks_ Healthcara servicos ar0 operaled by Care UK {Clinkal Serires) Llmited on behalt of the NHS Ragiatered in Englard Registration Numbar: 03462881, Registered pffce: Connaught House @50 Tho CresconL Colcheater Buaineas Park_Colchester, EsEex CO/49C3, RKCEIVED 78 CORONER (4 AM Way

As provider of healthcare servlces wlthin 1 custodial setting, Care UK is cognisant &f the framework provided by relevant Prison Service Instructions; PSI 74/2011 First Days in Custody (a cOPY of which Is attached for ease of refererce} stipulates that Informiation on Individual prlsoners should be Identilied at the polnt oi entry to the Prison and for that Information [0 be recorded and shared with other departments and agencies; bath internal and external, The PSI sets out the requirement for the Person Escort Record (PER) form that arcompanies each new prisoner, and ay other available documentation; to be examined in Reception bY Prison staff to identify any immediate needs and risks already recorded. Communication is in all areas ad Care UK staff are expected to develop close partnership working wlth the Prlson t0 ensure that relevart Information sharlng occurs Ir the best Interest of the prisoner to ensure their safety, We recognise that early identification of risk factors and effective management af prisoners in relation to self-harm is imperative in addressing the incidencE of guicide. The Care UK Suicide Prevention Strategy (a cOPY of which Is attached} draws on national external and Internal evldence relating to risk factors associated with suicide ard provides 3 framework for Iocal teams to address this vital area In their prison. 4 number of the mcasures Identified in the Suicide Prevention Strategy have relevance t0 the concerns You have ralsed, As stated above, Care UK was notthe healthcare provlder at HMP Lartln atthe tlme pf Mr Sargent'5 death; Going forward, the Care UK suicide prevention strateCy will be shared and rolled out across all sites_ In addition since taking over healthcare responsibility on 1 April 2016,Care UK plans to review the reception screening process to introduce J standard template for first reception screening aCross its prison healthcare settings are also looking at the process of information gathering on reception and the culture around this_ will expect staffto ask "Where Is the information for this patlent?" andthe SystmOne template wlll reflect this, ensuring that staff cannot proceed without seeking out the information and recording reasons whY; in instances where the information is not available: We will ensure our processes for obtaining information on reception are clear and effective and build relationships with local community providers to improve information flor Furthermore, ie will record lack of information at reception on cur incident system so that WE understand the extent ofthe issues andcan monitor trends and share practice. We recognise that we cannot rely salely an the first night receptian and that on-gaing assessment over several days is essential in orderto ensure we are aware of any changing clinical picture andto take account of any new Information that arrives. Since the death of Mr Sargent, discussions have been held with Prison colleagues t0 revlew communication pathways between the Frison ard Healthcare Services Thesz discussion; are on- going
3) There wos 0 concern that Healthcare stoff were not mode owore of prisoners who arrive wlth an ACCT history ond it wos suggested thor Healthcare should be informed in oll cases where prisoner arrives Qt Reception wlth Gn ACCT history 50 thot there is 0 continued sharing of pertinent Infarrnation Fagez083 key key rising Long We We goad

There wOS 0 concern thot the Prisoner Escort Record (highlighting concerns ond rlsks} wvas not supplled t0 the Healthcare Departrent rurses at Reception It WGs suggested that this should be an imperative requirementfor the further sharing of relevant informotion: These two polnts raise similar issues and can be answered together It Is the responslbility of prison service staff to share Infarmation with other departments and agencles both Internal and external: FSI 74/2011 (First Days in Custodyl sets out the requirement for the Person Escort Recard {PER} form to be examined in Reception bY prison staffto identify any immediate needs and risks and for this information to be forwarded to other staff and agencles as necessary, including healthcare. PSI 74/2011 sets out the mandatory requirements for prison staff and healthcare in respect of prisoner'$ ACCT status ACCT alerts and risk asse5sments Care UK thus expects PSI 74/2011 +0 be followed and that prison personne will record 2 prisoner's ACCT status pn their record and share this and any concerns wlth Healthcare. In order to ensure robust communication and partnership working going forward we !ill continue to work closely with our prison partners on this and in particular, the Head of Healthcare Is working to address the concern with the Safer Custody Governor, In addition, all Iprison and healthcare) staff havc been reminded that must se@ the PER on every occasion and that non-access should be escalated within the prison via a datix incident report; If the staff member does not have access, an incident form should be completed a5 soon a5 it i5 apparent that a PER isn't available this letter answers Your concerns, however; please do not hesitate to contact me I You require any further information, Yours faithtully Hi Hc( 6 Lorralne McMullen Regional Services Manager Fage 3of 3 they hope

Dear Mr WlaMs Thank you for your Regulatian 28 report dated Apn 2016 addressed t0 the Government Legal Department concerning the rerent inquest Into the death of Matthew Sargeni on 28 September 2014 a HMP Larin; Your lelo: has been passed Io Ihe Equality Righls and Decency Group In NOMS 2 we have policy rebponsiblllly Ior suicide prevention and self harm management and for sharing leaming doaths in custody. have consulted with the Govemor a HMP Long Lartin In formulating this response. As you will be aware, we wark hard to learn lessons from cach Death in custody, and In paricular look l0 rucommendationg recent Inveatigations by Ihe Prisons ard Probalion Ombudsmon and Coroners Inquestz t0 WS identify areas for Improvement wouid Ilke t2 thank You for drawng Qur attention to Ine issues You rise in your report and assure You that these have been considered by the prison; The actions that have been, Or are sopn to be, implemented are set out Delow Personal Qificer Schomg Lartin 8 Pergonal Olficer policy etates that Ihat Personal Oficerg Meei with prisonerg on an Informal or fcral basls weekly to discuss any Issu85 Of concers and tnat j record 0l these dlscussions bo Made In (ne ca8e-notes On PNOMIS &0 that all Information is epproprlalely shared For staff absences of over two wceks on ol (ne supForting Personal Omcers In the team will take 0n the role Following your concers regarding the operation of tho Porsonal Oticer echeme a HMP Long Lartin the prison will ensure thal all statf are reminded of the pollcy: This will be achieved through a range of communicatons with sta#f incruding the issuing of Safur Custody Bulletin and dissemination tnrough Custodial Managers, The elfectiveness of the Personal Officer gcheme ia monitored on 2 monthly basis, with Supervising Officers checking all case-note entries and ensuring that Buppor olicers are in placo_ Custodial Mangers alsp camy out quality checks 07 both Managoment checks and caso-note checks This i8 compleied monthly and these checks will bz recorded on PNOMIS Way Long from from help Long will ill

Historcalinlomation weg noLreulewed bK olicer andhealthcarg gtf Yout repon ralses the concem that staff did not acce8s historical Infommaton when Mr Sargont frst prosented at tho prison ad suggested that an instruction be issuod that stali should make enquires regarding this information can conlrm that In response t2 this concern; process ha8 been in placa Io ensure that staff ACCD3S t0 historical Inlormatlon where this infonation is avallable Ottender Management Unit staff are now rosponsible for ensunng that historical nisk indicators ar dlssemlzated to Healncare_ Reception and tho Saler Prisors team This infomation is drawn from Ihe pre-transter report (a document which includes all the prisoner's details including ACCT Inlormation and case notes), which Is sent to the receiving establishment bafore @ pisoner is iransforted Healthcare_ataff_wete_not madgjur_oL prsonerg_whoarnve with J ACCI haton Consideration has been given a3 to how to ensure Healihcare stalf are Made aware of prisonera who arive with an ACCT histary, and action taken to regolve this It is now the case that when € Newi pnzoner who has an ACCT history Is received into Long Lartin, reception staff notify hea thcare by phone in first irstance Following this , Healthcare will alsp receive CoPY o the firstnight induction Papenwork, which Is completej with the prisoner and givos dotails of any ACCT history; This documentalion Is sent wlth Ihe prisoner as part of the Prisoner Escort Recor {PER) when attend Healthcare, ensuring that any information regarding relevant SSuos at avallable I2 stalt, Iho Pukonor Egcon Rocond hlohligbtlng concemgandlskalwaa not supplied ttheHealthgare Qapammed On completion of Mr Sargent $ inquest a New procesb wa implemented in the rBception department whereby the PER fom is now copled and taken to Ire healhcare deparment with the prisoner: Once staff have completed the first nighi Induction paperwork wth Ihe Prisoner; reception staff will scnd of this immediztely to healthcaro with Ino PER fon; Tnis provides heatthcare with all knowm detais of the prisoner's risks inctuding any history of sel-ham hope this provides you with asguranca inat the Matters Df concern you have Idenlified have been addressed Yours slncerely PuI gain ine thney copy ine