Dear Ms Topping,

Re: Regulation 28 Report to Prevent Future Deaths – Haydar Jefferies who died on 5 March 2023 at Frimley Park Hospital whilst under detention at HMP Coldingley.

Thank you for your Report to Prevent Future Deaths (hereafter ‘Report’) dated 20 December 2024 concerning the death of Haydar Jefferies on 5 March 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Haydar’s family and loved ones. NHS England is keen to assure the family, and the Coroner, that concerns raised about Haydar’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Haydar’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raises the concern that, outside of weekday office hours, there is no mental health clinical provision and that overnight staffing levels at HMP Coldingley make it difficult for prisoners in mental health crisis to be taken to hospital. As a result, you raised that:

a) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions; and

b) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30pm and 7.00am the following morning.

I note your concern around overnight staffing levels and the lack of clinical presence overnight, outside of weekday hours. For clarity, I can explain that not all prisons in England provide 24-hour healthcare so there is no overnight clinical presence. HMP Coldingley is a Category C establishment, which means it is considered as someone’s ‘usual residence’, or home. There is therefore no provision for overnight healthcare.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

12 March 2025

In the event of there being serious concerns about an individual’s health, it is expected that a 999 call is made to request an ambulance in the same way an ambulance would be called for a person in their own home. This falls under what is described as ‘urgent referrals’.

I would also like to inform you that since Haydar’s tragic death, the healthcare at HMP Coldingley, including mental health services, has been re-commissioned.

As of 1 April 2023, the new provider is contracted to provide the following:

• Primary care services: Delivered seven days per week between the hours of
07.00 and 19.00 Monday to Friday, and between 08.00 and 17.30 on weekends and public holidays.

• Mental health services: These services are delivered seven days a week at a minimum, Monday to Friday 08.00 until 20.00 and ‘on call’ from 10.00 until
16.00 on weekends and public holidays. There is also on-site attendance available seven days a week.

Within the new contract, if there is a requirement for any emergency treatment, such as medication to alleviate any mental health symptoms, for example, the following applies:

• Emergency referrals: Must be made within two hours when primary care services are on-site

• Urgent referrals: Must be made within twenty-four hours, with protocols in place with out of hours (OOH) service providers to manage any urgent cases that arise during the OOH period. These are provided through Integrated Care Board (ICB) commissioned services or specialised services. This also includes 999 calls where there are serious concerns as mentioned above.

Contract Management Processes are in place to ensure that emergency and urgent referrals are reviewed and monitored regularly. This is a quarterly process which is audited and recorded. With regards to any urgent issues identified, these are reported via Datix (a digital system for reporting incidents and risks used to support risk mitigation and regulatory compliance) and acted upon immediately.

The Service Specification for primary (medical and nursing) and dental care provision in prisons, published in 2020, and the Service Specification for integrated mental health service for prisons in England, published in 2018, both support the regional commissioning and contract management process for primary care and mental health service provision. These service specifications detail core service delivery and the standards that providers are expected to prioritise, including expected outcomes.

A review of the NHS England health and justice service specifications is being undertaken by NHS England through 2025 to 2026, and any learning from this case will be used to ensure that the primary care specification continues to support commissioners to be able to tailor services to meet the needs of their prison population.

In addition to this, NHS England and His Majesty’s Prison and Probation Service (HMPPS) are working collaboratively to produce the Joint Care and Separation Unit Standards Framework. This will be rolled out later in 2025, along with a range of resources to support implementation, at establishment level, once the Segregation Policy Framework is published. This supports a multi-disciplinary approach to healthcare, including mental health, for people in segregation. There will be a planned implementation phase to support healthcare, and governors will adopt the standards over an agreed period, which will be determined by HMPPS.

I note your Report also directs a concern to both NHS England and HMP Coldingley, that the Assessment, Care in Custody and Teamwork (ACCT) process is not designed, nor effective, to protect prisoners in acute mental health crisis who do not appear to be suicidal.

Ownership of the ACCT process and policy lies with HMPPS. NHS England are therefore not able to comment on this point and would recommend that this is directed to HMPPS for a full response.

The findings, information and any learning from this case will be tabled at a future NHS England Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both national and regional teams. All health and justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified.

NHS England’s national health and justice team has also engaged with colleagues from the South East region on the concerns raised in your Report. For improvements to be made, a notice will be issued to healthcare staff that they should record a case note when they ask prisoners if they are having thoughts of self-harm, and they will be advised that negative responses should also be recorded. Good order and discipline reviews will now include questions around prisoners’ thoughts on self-harm and responses will be recorded, and mental health teams will log all referrals on SystmOne. A new template form for mental health referrals is also being designed, which will include prompts to include key information to aid triage and details on what to do with the referral. HMP Coldingley’s Governor will ensure that the new template is circulated to all operational staff.

I would also like to provide assurance about the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learning and insight around events, such as the sad death of Haydar, are shared across the NHS at both a national and regional level. This helps NHS England pay close attention to any emerging trends that may require further review and action.

I would like to thank you for bringing these important issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Ms Topping,

Thank you for your Regulation 28 report of 20 December 2024, addressed to the Minister of State for Prisons, Probation and Reducing Reoffending, and to the Governor of HMP Coldingley. I am responding as Director General of Operations for His Majesty’s Prison and Probation Service (HMPPS).

I know that you will share a copy of this response with the family of Mr Jefferies, 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 concerns about the recording and sharing of key risk information and around mental health awareness. I will address each of your concerns that relate to HMP Coldingley in turn.

Firstly, I wish to clarify that the prison sent an updated copy of the safer custody policy document, named the Safety Strategy, by the agreed deadline of 18 December 2024. As you have been provided with a copy, I will not detail the changes made to the policy but can assure you that the strategy does set out relevant action which addresses the concerns you raised during the inquest.

You have raised concerns that there is no system in place to record welfare concerns about prisoners when they are reported into the prison, and that when matters of concern are recorded this is not always documented in the same place. I have received assurance from the Governing Governor of HMP Coldingley that the prison has developed and embedded a new process to ensure that important information relating to the welfare of prisoners is recorded and shared appropriately. Any contact from a concerned relative or friend of a prisoner must be logged as a case note on P-NOMIS, the National Offender Management Information System used by the prison service, and the Safety team must be informed. That information is then added to the daily briefing sheet and discussed at the next Safety Intervention Meeting (SIM), a weekly multi-disciplinary meeting where the most at risk

OFFICIAL OFFICIAL prisoners are discussed. This requirement has been added to the updated local Safety Strategy. You may wish to note that in response to Mr Jefferies’ death, the prison now discuss prisoners serving an Imprisonment for Public Protection (IPP) sentence at the SIM.

I understand that your concern that relevant risk information was not consolidated in one place and disseminated in daily briefing sheets was addressed by the prison in a letter sent to you on 18 December 2024. I do not wish to duplicate the response but can assure you that the prison remains committed to ensuring that relevant information is identified and shared appropriately.

You have raised a concern that there is no composite document for clinicians to review which contains relevant information recorded by prison staff about prisoners in the Care and Separation Unit (CSU). There is now a morning briefing for CSU staff, attended by healthcare and the mental health team which takes place prior to healthcare’s rounds, when all CSU prisoners are reviewed. Documented concerns are shared each morning at the briefing. Collaborative working and communication between prison staff, healthcare and mental health colleagues has improved through multi-disciplinary meetings which support the sharing of relevant risk information and actions to help prisoners identified as at risk of suicide and self-harm.

Your final concerns relate to prison staff’s awareness of mental health, including making referrals to the mental health team and recognising when a prisoner’s mental health is declining. Following Mr Jefferies’ death, the mental heath referral process was reviewed and the referral form was redesigned to simplify the process. The form is now available electronically so that staff can easily access it when needed, and when a referral has been requested by a senior member of staff they must document that this request has been made and record the name of the staff member tasked with completing the referral. Through improved multi-disciplinary working, there are more opportunities to check that referrals to the mental health team have been completed and received by the mental health team.

The prison is piloting an online e-learning course called ‘introduction to Mental Health’ for all staff working in the CSU to support staff in identifying indicators of declining mental health and to upskill staff to complete the mental health referral forms with relevant risk information. All new staff applying to work in the CSU must complete this course.

The prison’s Safety Strategy also sets out that all managers, particularly night Orderly Officers and those in charge of the prison when healthcare colleagues are not available must consider using out of hours options when concerns for a prisoner’s mental health have been raised. This includes phoning 111 – the NHS emergency non-life threatening phone number which now offers mental health crisis support.

In addition to the action taken locally at HMP Coldingley, I can confirm that all new prison officers complete a training module called ‘Introduction to Mental Health Awareness’ as part of their initial prison officer training.

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

Dear Ms Topping

Haydar Jefferies (Deceased) ( ) - Death in custody on 5 March 2023 - HMP Coldingley

Please find enclosed a copy of the Safety Strategy Policy dated December 2024, for HMP Coldingley. The updated policy encompasses the key learning outcomes following the sad death of Haydar Jefferies.

The two further queries and responses are dealt with as follows:
1. The fact that says that the new referral form does not always include enough information? As outlined on page 12 of the December 2024 Safety Strategy, the prison is rolling out mental health training for Custodial Managers and CSU Staff to assist with populating the referral form with all relevant information in respect of risk and to support custodial prison staff in identifying mental health concerns more readily. Custodial Managers can check that mental health training has been completed by accessing officer training records through the online management system. Any new staff that have successfully passed a board to work in the CSU, must have also completed the online training prior to being invited for interview. The prison expect all existing staff in these positions to have completed the training by the end of January 2025 and that new recruits into these positions will be required to complete the training before taking up post. The prison is committed to ensuring mental health concerns are referred to the mental health team as early as possible. This may mean on occasion that the information is slightly more limited than the mental health team would like in order to gain a comprehensive understanding of the issues, but this at least puts the mental health team in a position to make further enquiries and bring their expertise to the assessment urgently. It is important to acknowledge that the referral form is designed by the Mental Health team. The Prison is willing to publish an amended version if the Mental Health team identify that they require the inclusion of specific information. Assistant Coroner Topping HM Coroner for Surrey HM Coroner's Court Station Approach Woking Surrey GU22 7AP Litigation Group 102 Petty France Westminster London SW1H 9GL T 020 7210 3000

Your ref: Haydar Jefferies (Deceased) Our ref: 18 December 2024

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2. The jury finding that records are across multiple systems with different levels of access with no set expectation for cross referencing.

The prison is committed to ensuring information is captured and disseminated efficiently and effectively. Certain information needs to be recorded in specific areas/working logs to ensure that information is noted by the correct staff members who then filter and prioritise the information so that it is actioned meaningfully. Necessarily there are systems to filter and distil the information to key facts and issues, otherwise, there is a real risk of information overload. For example, what is useful and important for a wing officer to read in the Observation Book may be excessive detail for the senior managers to read in the daily briefing sheet.

It is also important to note the necessity of having a separate healthcare system to ensure patient confidentiality.

To drive improvement in terms of better cross referencing of information, there is now an expectation that any contact from a concerned relative or friend of a prisoner is recorded as a case note on P-Nomis and the Safety Team will be notified of the interaction. The entry is then added to the Daily Briefing Sheet and discussed at the next Safety Intervention Meeting. Where applicable, there is also an expectation that these entries are captured in other areas such as the Wing Observation Book, ACCT records and/or Mercury Intelligence Reports. These requirements have been implemented in the December 2024 Safety Strategy Policy as annexed to this letter. The importance of logging calls has been communicated to staff by weekly video links, a notice to staff and discussed at staff briefings. Any failure to comply with this requirement will be challenged and may result in disciplinary or performance management action being taken.

We do hope this clarifies the position of the prison.

If the prison can be of any further assistance, please do not hesitate to get in touch.