Dear Sir Regulation 28 – Prevention of Future Death Report: Mr Daniel Davey - HMP Bullingdon I am writing in response to the Regulation 28 report which you issued following the inquest touching on the death of Mr Daniel Davey, a prisoner at HMP Bullingdon. Care UK would like to express its sincere condolences to Mr Davey’s family and friends. In your report you raised two issues of concern, both of which are addressed to Care UK, in its capacity as the healthcare provider, our sub-contractor Midland Partnership NHS Foundation Trust, and also to Her Majesty’s Prisons and Probation Service who will respond separately to the concerns raised. Concern 1: Healthcare attendance at ACCT reviews.

It would be helpful if there could be a further level of reassurance provided about, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.

Response In your report you highlighted “Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone).” This status continues to be supported by Care UK’s Local operating procedure (“LOP”) for “Healthcare attendance at ACCT’s”. This LOP was reviewed and updated in February 2019 and ensures a member of healthcare staff is detailed daily to attend the day’s planned ACCT reviews. This member of staff can be contacted daily via radio from 08.00 until 17.00hrs. Any requests for healthcare attendance at new ACCTs opened throughout the day are communicated from the prison to the Healthcare Coordinator. All ACCT reviews are added to the SystmOne Ledger and appointments closed down on the system to demonstrate and record completion of the ACCT review.

Care UK continues to work closely with the HMP Bullingdon Safer Custody department to improve partnership working throughout the management of the ACCT process. In order to ensure continued healthcare attendance to ACCT reviews a new electronic quality assurance process has been introduced. This is supported by Safer Custody staff spot checking compliance and escalating where necessary.

Concern 2: Reviews of ‘in possession’ medication risk assessments.

a. It would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed.

b. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary.

Response I can confirm that HMP Bullingdon is fully compliant with Care UK’s mandatory monthly audit in ensuring all prisoners have an ‘in possession status’ recorded on their medical notes from reception. HMP Bullingdon also adheres to the Care UK “In possession policy for Prisons” which reviews ‘in possession’ status:
1. After any relevant incidents
2. If the prisoner’s circumstances change or medication is no longer deemed appropriate
3. Following the opening of an ACCT document. The “CUK Health contribution to ACCT” template also supports and prompts healthcare staff to complete an ‘in possession’ risk assessment when documenting, an ACCT has been opened and to review when attending an ACCT review.
4. Or otherwise when a member of healthcare staff believes it to be necessary, e.g. concerns are raised that the prisoner is being bullied.

I would like to provide assurance that random spot checks are undertaken to support concordance and reduce the risk of diversion or stockpiling for overdose. These spot checks are undertaken by a member of the healthcare team supported by prison disciplinary staff. Where there is a discrepancy between the numbers of tablets a patient should have and the number found, the patient is reviewed to see if the medication is still required or if it needs to be moved to not in possession. At any point in time, any member of healthcare staff having concerns regarding patient safety can ask for the In-possession status to be reviewed to ‘Not In-possession’ by contacting the prescriber. This would be clearly

documented on SystmOne. In-possession status can also be removed, whilst the review is pending. I have met with the Safer Custody Governor and discussed the need for prison staff to have a joint responsibility when considering ‘in possession’ medication is a potential risk. The Safer Custody Governor is recommending this awareness is included in case manager training and is taking this action forward. I trust this provides assurance that Care UK is committed to working in partnership and improving processes to support the safety of men whilst at HMP Bullingdon. If you would like to review copies any of the policies or procedures mentioned in this letter please let me know.

Dear being day being key likely -

New electronic quality assurance checks are to be introduced and embedded by the end of August 2019, and these will include checking healthcare attendance at reviews_ In the meantime, the safer custody department is performing spot checks to monitor progress_ At national level we are working to improve the ACCT case management system and piloted a new version of the form and associated guidance in ten prisons during the spring of 2019. We realise the importance of the healthcare contribution to ACCT, and NHS England, and their Welsh equivalents have been involved in this pilot project. The revised form and guidance are clearer about the expectations of healthcare staff: We are currently evaluating the pilot and plan to implement the new model nationally during 2020. We will ensure that the learning from this case is used to inform the development of the materials that are used t0 inform the national roll out of the new model. Your second concern relates to reviews of in possession medication risk assessments. understand Care UK and Midlands Partnership NHS Foundation Trust will be replying to you separately on this point At Bullingdon;, if the ACCT case manager is concerned about the immediate welfare of an individual are required to conduct a review immediately, and to ensure that there is healthcare input to that review: The prison has issued guidance to all case managers stating that in possession medication is one of the topics that should routinely be discussed in ACCT reviews, and that a risk assessment must be conducted, informed by the advice of healthcare staff. If this advice is not immediately available then ACCT case managers can at their discretion remove in possession medication until can confirm that it is safe for the prisoner to continue to have it in their own possession: Lastly, you asked about the policy for cell searches for stockpiled medication. The safer custody department has distributed a safety briefing on in possession medication to all staff to ensure that are aware of the risks and know what action to take if they discover unusual amounts of in possession medication when conducting fabric checks or cell searches_ In future, the issue of stockpiled medication will also be covered in the local ACCT case manager training so that, when immediate actions plans are completed, consideration is given to the need to check for and remove in possession medication as temporary measure before a full assessment and review has taken place This is in line with existing national policy, and we will ensure that this continues to be the case, and that it is prominent in the guidance that is issued when revised version of ACCT is rolled out, so that the learning from Mr Davey's tragic death is shared as widely as possible_ Thank you again for bringing these matters of concern to my attention_ hope this response provided reassurance that are fully addressed at Bullingdon and at national level:

Dear Mr Salter RE: Daniel Daver Thank you for your letter dated 16'h 2019, reporting a matter to US, in accordance with Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013. May take this opportunity to reassure you that following Mr Davey's death, we undertook a thorough investigation into the care delivered by the Trust: Following discussions with all parties, am now in a position to respond to your concerns Matter of Concern 1: "Healthcare attendance at ACCT reviews: It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews. This is a significant concern and it is not in accordance with Iocal and national policy. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance andlor input (perhaps over the phone):' You would like 'reassurance provided about firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly process of auditing ACCT reviews in order to pick up cases where there is no healthcare input" _ Together we are life MPFT better for OuI communities May making

Response; We continue to work with colleagues in Care UK and the prison to ensure we support attendance at ACCT reviews and maintain the improved processes. We comply with the Care UK Local Operating Policy for Healthcare and Subcontracted teams input into the ACCT process_ The Local Operating Procedure identifies there is an expectation that the staff attending the ACCT record this on SystmOne and future reviews are diarised for attendance_ We will actively contribute to quality assurance checks of compliance with this Local Operating including those done as part of the PROTECT audits and are committed to improving our service delivery in response to any actions identified within these checks_ In addition we will work with Care UK and the prison in the development of procedures for escalation should healthcare, for any reason, be unable to attend an ACCT review. Matter of Concern 2: "Reviews of mental health "in possession medication risk assessments: relates to prisoner placed on an ACCT, Initially template is used at the prison healthcare screen to determine if medication should be held in possession or not This is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK's policy. In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29th December that he had plan to kill himself: You would like reassurance that the in possession risk assessments are reviewed: A related concern was that information about in possession medication was not available to prison officers thus there could be a time delay between a person experiencing a mental health crisis and healthcare involvementlreassessment; potentially leaving the person with access to in possession medication at a time of crisis:" Response: As was stated at the inquest, our prescriber's always record on the prescription form whether the medication they are prescribing should be held in possession: We have reminded our staff to ensure when are reviewing any medication that where necessary, include an update of the Medication In possession risk assessment which goes onto SystmOne, which in turn will feed the ACCT, This ensures that both dispensing staff and prison staff are aware of any changes and respond accordingly, this will include the removal of any medicines currently being held. As part of the ACCT LOP we are committed to working with colleagues in Care UK, Pharmacy and Safer Custody regarding medication reviews and "stop checks Policy they they, into

In addition, this case has been reviewed with the staff involved and the learning shared that whenever a patient indicates changes in presentation in relation to serious self-harm , such as changes in suicidal ideation or plan, that in all circumstances this will trigger the opening of an ACCT. hope this response helps to address your concerns. However if you require any further information please do not hesitate to contact me