Dear Madam,

Regulation 28: Prevention of Future Deaths Report – Kayleigh Ann Melhuish

I write in response to your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus Group on 4 December 2024 following the inquest touching upon the death of Kayleigh Ann Melhuish at HMP Eastwood Park. Practice Plus Group would like to express its sincere condolences to Kayleigh’s family and friends.

This response addresses the matters of concern in so far as they relate to Practice Plus Group only.

Matter of Concern 2: Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken.

Response: We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions. Unfortunately, Practice Plus Group’s ability to makes changes to SystmOne is limited and this would require action by TPP who own and operate the software. We have forwarded a copy of the Prevention of Future Deaths Report to TPP for their awareness. However, it is important to note that whilst a tick-box could serve as a prompt, it does not provide a mechanism for reporting or ensuring that meaningful reviews and updates are conducted.

To address this matter effectively, we remain committed to maintaining robust oversight through regular audits of ACCT reviews. These audits will ensure that care plans and associated support actions are being reviewed and updated appropriately.

Additionally, we will continue to collaborate closely with the prison to ensure all relevant staff complete updated ACCT training. This will reinforce the importance of thorough and consistent care plan reviews as part of the ACCT process. As at today’s date, 78% of all clinical staff have completed ACCT training and we continue to work with the prison to ensure access to regular ACCT training sessions.

Practice Plus Group conduct regular audits of the ACCT process, in October and November 2024 Healthcare attended 100% of all ACCT reviews and this is documented on SystmOne. We will continue to monitor this process.

It is important to note that at the time of Kayleigh’s incarceration Practice Plus Group was not a provider of healthcare services at HMP Eastwood Park. Of note, following the last inspection by HM Inspectorate of Prisons and the CQC in October 2022, there were very few recommendations for healthcare at the time. Practice Plus Group actioned all recommendations, having only taken over the contract a few days prior, and have a continuous Quality Improvement Plan in place.

I hope that the above response provides assurance that Practice Plus Group are committed to providing a high-quality healthcare service at HMP Eastwood Park and trust this response addresses the concerns you had.

We would like to end our response by taking the opportunity of inviting you to visit the healthcare team at HMP Eastwood Park should you wish to discuss and review first-hand the enhancements set out in this letter.

Dear Ms Voisin, Thank you for your Regulation 28 Report dated 4th December 2024 concerning the tragic death of Kayleigh Ann Melhuish who died on the 7th July 2022. I would like to begin by offering my sincere condolences on behalf of the Trust to the family and friends of Ms Melhuish. In your report you highlighted your concerns in relation to: ACCT reviews – Training re: Review/Update of Care Plan & support actions. The Trust has reviewed our involvement and input into the ACCT process, and revised the Local Operating Procedure for ACCT attendance (attached). This was discussed and signed off at the service level Quality and Standards meeting on 22nd January 2025. To ensure adherence with this procedure, the Quality and Standards meeting will monitor completion of ACCT training and refreshers through an audit schedule, which will also include monitoring improvements in standards across record keeping in ACCT and SystmOne. Ms Maria Voisin HM Senior Coroner for Avon Coroner’s Court Old Weston Road Flax Bourton Bristol BS48 1UL

A Quality Improvement Plan has been developed to support this and is attached. I hope this letter and attachments provide assurance that the Trust takes learning very seriously and that we have taken action to address the concerns you raised. I would be happy to meet with you and discuss our work to improve patient safety in more detail, or provide further information and assurance should that be helpful.

Dear Ms Voisin,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – KAYLEIGH MELHUISH

Thank you for your Regulation 28 report of 4 December 2024 following the inquest into the death of Kayleigh Melhuish at HMP Eastwood Park on 7 July 2022. I am responding on behalf of both HMP Eastwood Park and the Ministry of Justice. I am very sorry for the delay in responding to your report which was the result of an administrative oversight.

I know that you will share a copy of this response with Ms Melhuish’s family, and I would firstly 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.

Your report raises concerns regarding: the prevalence of neurodiversity within the population and a lack of related training for staff; inadequacies in understanding amongst staff of Assessment, Care in Custody and Teamwork (ACCT) processes, including when to use constant supervision, and the existence of a ligature point in one of the residential units at the prison.

As you heard in evidence at the inquest, HM Prison and Probation Service (HMPPS) is undertaking significant work to understand and raise awareness amongst staff of neurodiversity issues and the impact that they can have in the custodial environment. In recognition of the importance of such issues, staff undergoing initial training receive training on diversity and inclusion, personality difficulties and neurodiverse conditions including autism are discussed and consideration is given to how staff can support prisoners with these needs. This training covers issues such as how best to conduct searches of individuals and how to manage disciplinary processes that may impact negatively on those with neurodiverse conditions. For existing staff, the online learning platform to which all staff have access

contains training modules relating to neurodiversity including Neurodiversity-Autism/ADHD and Neurodiversity-Learning Disabilities and Challenges.

We have recruited Neurodiversity Support Managers (NSMs) across the prison estate to ensure that support for neurodiverse prisoners is consistent across all education, skills and work opportunities as well as the wider prison. One of the main responsibilities of the NSMs is to provide training and support for other prison staff to help them better understand and support those with neurodivergent needs within the prison. The NSMs are also responsible for implementing a whole prison approach to supporting neurodivergent needs with improved processes. This can include ensuring that all information and forms are available and/or designed with suitable adaptations, and that reasonable adjustments are made for prisoners with a disability so that they are not unfairly disadvantaged and can access all parts of prison life. We have also developed a ‘National Neurodiversity Training Toolkit’ that is available for all frontline staff within prison and probation, developed by and with neurodivergent staff, in cooperation with HMPPS and Ministry of Justice staff networks.

Eastwood Park has employed a Speech and Language therapist and a Neurodiversity Strategic Lead to work alongside the local NSM. The NSM delivers an introduction on neurodiversity to all new staff during their training period. This session includes highlighting common characteristics of neurodiverse people and best practices when working with them and provides staff with the opportunity to ask any questions they may have to deepen their understanding.

Turning to your second concern, I agree that it is essential that ACCT procedures are understood by staff, and in particular that ACCT case co-ordinators are aware of the importance of reviewing actions at case reviews and are confident in knowing the circumstances in which constant supervision would be appropriate.

These issues are covered in the case review training that is provided to ACCT case coordinators, and a case review refresher course is also available for staff to attend. A new quality assurance process for ACCT has also been developed and provides an opportunity for managers to offer feedback to case co-ordinators to enhance their performance.

At Eastwood Park the standard of ACCT case management is monitored through the quality assurance process. Any concerns identified are raised directly with the case coordinators and support sessions are provided for staff. Where concerns continue, these are escalated to line managers. The prison is also facilitating forums for case coordinators to allow further discussion about the ACCT process and supplementary information is shared with staff through the safety Microsoft Teams channel.

In the light of your comments the local procedures in relation to constant supervision at Eastwood Park will be reviewed. The Governor expects to complete this work within a month and any changes will be communicated through staff briefings. Additionally at a national level

the Safety Group is currently undertaking work to develop further guidance for prisons on constant supervision, which is planned for completion by the end of March 2026.

You identified the existence of a ligature point on Residential Unit 3 at the prison. Whilst we aim to minimise the presence of ligature points, including by ensuring that all new and refurbished accommodation meets ligature resistant standards, we are not able to remove all such points across the estate. At Eastwood Park, four ligature resistant cells, spread across three residential units, have been installed for use for prisoners who have been identified as being at risk of suicide by ligature and are expected to come into use shortly. The prison will continue to support prisoners at risk of suicide by ligature with other measures through the ACCT case management system and the case review team would decide on actions such as whether to remove items that can be used to ligature or constant supervision where appropriate to manage the risk.

Thank you again for bringing your concerns to my attention and I trust that this response provides assurance that we are addressing them.