Dear Mr Simblet

Carol Taylor (RIP)

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 12th June 2025 in respect of the above, which was issued following the inquest into the death of Carol Taylor (RIP) .

I would like to begin by extending my deepest condolences to Mrs Taylor’s family. The Trust sympathises with their very sad loss.

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to the concern raised in the hope that this provides both yourself and Mrs Taylor’s family with comprehensive assurance of changes that have been made at the Trust to address the concern you have raised.

Concern 1) There was no system that prevents staff that are non-compliant with mandatory training, including basic life support training from being able to work on EPUT in-patient wards

Response: Ward managers are able to access and review the skills of staff on the ward, which includes bank worker training compliance, via a training tracker. If there is a staff shortage then requests may be made for bank and agency staff, identifying the skill set required to ensure those booked onto shift hold the necessary skills / training to deliver the required care competently.

A ‘bar’ on temporary staff / substantive working on the ward unless they are compliant with all mandatory training, including basic life support training brings the significant risk in relation to having the necessary number of staff on shift however compliance with mandatory training is vital. To address this Ward Managers actively manage compliance with mandatory training.

Ward managers have access to training trackers which are checked on a monthly basis during substantive staff member’s 1:1 support meeting. As soon as a training is showing as Amber which shows that training will be non-complaint within three months, staff are supported by the Ward Manager/Supervisor to book into that training before it expires. Bank staff training compliance is checked by the ward manager/charge nurses when they are booked. If they are non-complaint for training, this is escalated to the temporary staff manager. Staff who are found not to be compliant are supported during their 1:1 support meeting with their supervisor

to book onto trainings by their supervisor or ward manager. Mandatory training is reviewed by the Clinical Manager/Matron on a monthly basis with Ward Managers in their management meeting. We hold a locality performance and accountability meeting with Ward Managers and Clinical Leads chaired by Associate Director with a focus on Mandatory Training compliance and performance.

Mandatory training is monitored through the Quality of Care and Accountability Framework meetings on a monthly basis. The Accountability Framework meetings are chaired by an Executive Director and attended by supporting executives and directors and the Care group leadership team who present their performance for the month, mandatory training is a key focus.

Concern 2) This is a particular concern generally, but especially in hospitals such as St. Margaret’s where at least some of the wards specialise in treating elderly patients who are likely to be at greater risk of medical collapse than the general population.

Response: Following on from our reply under concern 1 above, all staff working on EPUT wards and clinical areas, are inducted on the process for summoning help in a medical emergency. This is covered in the Basic Life Support (BLS) and Immediate Life Support (ILS) training and is also highlighted on the attached two documents.

The Royal College of Physicians NEWS2 training has been undertaken by staff working at these sites and staff are signposted to the additional ‘364 Recognising & Managing Deterioration’ training which is available for all staff to access via the online learning portal. The Assessing a Critically Unwell Patient and ‘Non-Contact Physical Observations’ aide memoirs have been implemented Trust wide, in order to support staff members to carry out a robust ‘Head to toe’ physical health assessment of a patient. The situation, background, assessment and recommendation (SBAR) tool is utilised to provide a structured handover upon escalation, whilst the ‘Calling (9)999 in a Medical Emergency’ document assists with communication when contacting the Ambulance Service. Each Ward has a nominated Resus Link Practitioner to aid in sharing lessons identified and safety alerts and helping to facilitate regular medical emergency simulations within the clinical areas. These important resources and previous lessons identified were presented to EPUT staff via an online ‘Learning Matters’ event which was delivered on 25th June 2025 and the event was recorded for future access.

In addition, there is a Physical Health Task and Finish Group which has been formed to review the existing physical health provision on the Inpatient Wards. The Physical Health Competency Framework and Bite Sized Training support packages are amongst a number of resources which are currently being explored for implementation across the Trust. There are 84 Physical Health Link Practitioners in place across the inpatient Wards and the volunteers join the bi-monthly Resus Link Practitioner meetings where learning is shared. A ‘Physical Health Secondary Care planning Cycle’ has been piloted on a number of in-patient wards, with a view to implementing this Trust wide.

I hope that I have provided some reassurances around the steps that we have taken to address the issues of concern contained within your report. We know there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe.

Please do let me know if you require any further information at this stage, including copies of any of the documents referred to above.

We understand that a copy of this reply will be shared with the family.

Dear Ms Griffin, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – FRAZER WILLIAMS Thank you for your Regulation 28 report addressed to the Minister of State for Prisons, Parole and Probation, the Director General of His Majesty’s Prison and Probation Service (HMPPS), and the Governor of HMP Guys Marsh as well as to other agencies. I am responding as Interim Director General of Operations for HMPPS and my response addresses all concerns relating to HMPPS on behalf of the above named recipients. I am grateful to you for allowing us additional time to respond and apologise for the delay in providing our response. I know that you will share a copy of this response with Mr Williams’ 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. Following evidence heard at the inquest, you have raised a number of concerns. I will address those for which HMPPS has responsibility in the order of which you have raised them. Your report identifies a lack of guidance on the management of self-neglect in the prison setting. Informed by the learning from the investigations into Mr Williams’ death, guidance for prison and probation staff on ‘Managing Self-Neglect in Prisons and Approved Premises’ was published on the HMPPS intranet in July 2024. This is designed to raise awareness of the issue amongst staff and to equip them to work in partnership with healthcare staff to safeguard people who self-neglect in a prison or an approved premise.

Your report describes a lack of quality assurance of the operation of the Assessment, Care in Custody and Teamwork (ACCT) process. The Prison Safety Policy Framework that was implemented on 1 January 2025 mandates the use of a quality assurance tool which involves a three-stage check of ACCT documents, including a weekly check of all open ACCT document. At Guys Marsh this local assurance process is supplemented by the regional Safety Team which attends the prison twice monthly to undertake ACCT assurance and provide feedback to the establishment. Your report draws attention to the absence of a system for flagging missed ACCT reviews at Guys Marsh, and to the fact that relevant individuals were not being invited to reviews. A new booking tool was introduced in August 2024 to schedule reviews, and this also supports consistent attendance from relevant individuals. The safety team now highlights any reviews that have been missed to the Orderly Officer so that they can be rescheduled promptly. Your report notes that key work at Guys Marsh was not operating in accordance with key work national guidance. This has not been possible because of staffing issues, but the prison has been operating a priority key work scheme, designed to ensure that the most vulnerable men are seen regularly. A new shift pattern was introduced in September 2024 detailing officers to carry out key work to increase the delivery of key work sessions beyond the priority group as well as providing consistency with sessions being delivered by the same key worker where possible. I have noted your concern regarding the similarity in colour of cell doors and bedsheets, but I am not aware of any problems having arisen previous to this. I have passed your observations on to the national Safety Team to consider as part of their ongoing work on ensuring a safe physical environment for prisoners. Your report draws attention to local procedures at Guys Marsh that did not comply with national policy on when to call an ambulance. The Governor has issued a Notice to Staff that explains that it is mandatory to call an ambulance when an emergency code is called, and compliance with this expectation is regularly reviewed. Your report notes problems with the process for recording information about a prisoner’s next of kin at Guys Marsh. This has been reviewed, and the Offender Management Unit is now involved to ensure that the process is managed effectively. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address each of these issues.

Dear Senior Coroner, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – FRAZER WILLIAMS Thank you for your Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Frazer Williams, who died on 7 March 2022 at HMP Guys Marsh. I have read your report with care as a death in custody is a tragic event for families and friends, as well as other prisoners and staff, and learning lessons to improve the safety of those in prison custody is essential. I understand that you will share this letter with Mr Williams’ family and I would like to offer them my sincere condolences for their loss. The concerns you have raised within your report are operational issues and it is therefore appropriate that who is the Interim Director General of Operations, HM Prison and Probation Service (HMPPS), has responded to them. I have seen the response from and I endorse the content of it, which sets out the action being taken by HMPPS to address your concerns. Minister for Prisons, Probation and Reducing Reoffending