Frazer Williams
PFD Report
Partially Responded
Ref: 2024-0294
Coroner's Concerns (AI summary)
A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. The absence of a national directory for prison healthcare facilities exacerbated risks for prisoners with complex needs.
View full coroner's concerns
1. During the inquest evidence was heard that: i. On the 4th June 2021 Frazer, was placed at HMP Lewes where he remained until his release on the 4th October 2021 having served a sentence of imprisonment. On the 7th October 2021, he was remanded into custody and placed at HMP Winchester. He was sentenced to a term of imprisonment on the 10th November 2021 and was due to be released on the 25th March 2022.
ii. During his placement at HMP Lewes, Frazer presented with a deterioration in his mental health and remained subject to an ACCT due to an incident of self harm, and was also under the care of the healthcare team until the point of his release on the 4th October.
iii. Following his arrival at HMP Winchester, which has a residential healthcare unit, referrals were made to the mental health team. Frazer was assessed by a psychiatrist on the 20th December 2021 who felt that he was suffering with enduring psychotic illness and required further review.
iv. On the 14th January 2022 Frazer was transferred to HMP Guys Marsh. HMP Guys Marsh does not have a healthcare unit or a 24 hour in prison healthcare provision. The healthcare team operating hours are 7.30am to 6pm daily.
v. An email was sent from the healthcare team at HMP Winchester to the healthcare team at HMP Guys Marsh with Frazer’s name and that he was a person of interest. No other handover took place between the healthcare teams or the prison staff teams.
vi. Following Frazer’s transfer, the Head of Healthcare at HMP Guys Marsh raised an inappropriate transfer investigation as the clinical opinion was that he should not have been transferred to HMP Guys Marsh. Prior to Frazer’s transfer, there had not been a discussion with the healthcare teams at HMP Winchester and Guys Marsh by the prison service to consider suitability of Frazer’s transfer in view of the fact he was in the process of being assessed, and a confirmed diagnosis being made, relating to his mental health.
vii. The Associate Medical Director for Practice Plus Group (PPG) who provided the healthcare at HMP Lewes and HMP Guys Marsh when Frazer was at those establishments, confirmed that there is no national directory that explains what healthcare facilities are available at each prison and PPG have created one internally for the prisons they provide healthcare at. It was explained that this would assist when making decisions around suitability of location within the prison estate for prisoners, given their needs. Further if there was a national directory across all prisons this would greatly assist as PPG are only 1 of the 10 different healthcare providers across 114 prisons. He gave an example that he would not know how many disability access beds or cells there are at the prisons where PPG do not provide the healthcare. He also explained that there is no national specification in relation to healthcare units.
viii. Frazer was a person with complex needs. His mental health deteriorated at HMP Guys Marsh. He would spend most of the time in his cell, he generally did not engage with staff or ACCT reviews, and there were records that he missed and secreted medication. He held delusionary beliefs that if his toilet was flushed or he watched television, his family would come to harm. His cell was in an extremely poor state, littered with rubbish, an unflushed toilet and a bucket which was used for him to urinate and defecate in. This bucket was found to be full in his cell at the time of his death. It was acknowledged by the staff at the time he was self neglecting and he was referred to the Safety Intervention Meeting (SIM) process on the 9th February 2022. The Head of Healthcare gave evidence that there was not an adequate plan between the prison and healthcare teams to manage Frazer’s self neglect.
ix. There is no national guidance on how to manage self neglect in prison. HMPPS are currently finalising a Social Care Learning Brief on Managing Self Neglect which is expected to be issued later this year, however there is no NHS guidance on this issue or joint guidance between HMPPS and NHS as to how to manage self neglect in a prison setting.
x. Frazer’s mental health deteriorated to such an extent that following an assessment on the 9th February 2022, he was deemed to require transfer to hospital under Section 47 of the Mental Health Act 1983. The second doctor assessment was carried out the following day, 10th February 2022, and an application was sent to Ravenswood House Hospital, a secure unit within Southern Health NHS Foundation Trust on the 15th February 2022. Frazer was visited by the community psychiatrist on the 25th February 2022 when it was confirmed he required transfer to hospital for full assessment and treatment. The warrant was obtained from the Ministry of Justice for the transfer on the 1st March 2022. A bed was offered to HMP Guys Marsh by the hospital on the 1st March 2022 for admission on the 3rd March 2022, however, the prison could not facilitate an escort that day. The hospital could not facilitate safe admission on Friday 4th March 2022 or over the weekend, and the transfer was arranged for Monday 7th March 2022. Frazer was told on the 3rd March 2022 he would be transferred to hospital, however the evidence indicated he was not told when. At approximately 03.15am on the 7th March 2022 Frazer was found deceased in his cell, suspended by a ligature.
xi. The ligature was made from a ripped bedsheet attached to the top corner of the cell door. The bedsheet was the same colour as the door and had not been seen prior to his death, and was therefore camouflaged. I refer to the attached photograph of the cell door which shows the ligature in place. The colour of the cell doors in each prison is directed by the Governor of the prison and not by national directive, however the same bedsheets are issued nationally across the prison estate. The similarity in colour could be a national issue and apply to other prisons.
xii. An ACCT was opened in relation to Frazer on the 15th January 2022 and remained open until his death. Between 15th January and 7th March 2022 there were 11 case reviews. The ACCT records were incomplete and inadequate. The last case review took place on 1st March 2022. The next case review was scheduled for 3rd March 2022, however this did not take place and there was no further case review prior to Frazer’s death. The evidence did not reveal why this had not taken place. As the ACCT is a paper based system, a missed case review is not automatically flagged in any way.
xiii. Since Frazer’s death there has been the implementation of the ACCT assurance process nationally which requires the ACCT paperwork to be reviewed on 3 occasions as quality assurance or audit. Firstly, between 25 and 72 hours of the ACCT being opened, secondly at day 7 of the ACCT being opened and finally at the post closure review. If a person is subject to an ACCT for a lengthy period of time, there is a gap between day 7 and the post closure review where no quality assurance is required to be undertaken.
xiv. Frazer’s key worker at HMP Guys Marsh gave evidence that in an ideal world prison officers would sit down with a prisoner for 45 minutes once a week to undertake key work as per national guidance. He explained that the 2 key work sessions he had with Frazer lasted no more than 5 minutes and were conducted on the landing outside his cell whilst other people would be walking around the wing. This was due to the fact the officer had to run the wing at the same time and he therefore explained the keywork sessions were not effective. He confirmed that the keywork sessions he undertakes now with prisoners now would probably be no more than 15 minutes. He further confirmed he was not invited to any of Frazer’s 11 ACCT case reviews and to date he has never been invited to any ACCT reviews for any prisoner at HMP Guys Marsh, even as a prisoner’s keyworker.
xv. There is inequity in the system in that if a person is deemed detainable under the Mental Health Act 1983 in the community, they will be admitted to hospital straight away. If there is no bed available in a psychiatric unit they will be placed in an acute hospital where there is monitoring and access to medical care 24 hours a day. If a person is in need of hospital care and treatment under Section 47 of the Mental Health Act 1983, there are delays in the transfer to a hospital setting. When a prisoner suffers a physical health problem they can be transferred to hospital for care by ambulance or escort. With a mental health care problem, the appropriate paperwork needs to be completed, a hospital bed found and arrangements made for transfer before a person is admitted to hospital. During this time a prisoner may be placed, as Frazer was, in a prison without a healthcare unit and without 24 hour healthcare monitoring and care. The current legal timeframe for this is within 28 days. In relation to Frazer, his transfer would have been completed 26 days after he was first assessed Several witness said this was one of the quickest transfers they had experienced.
xvi. When a code blue or code red is called at HMP Guys Marsh, evidence was given that the control room do not automatically call an ambulance and before doing so, ask questions such as is the patient conscious and breathing. Annex A of Prison Service Instruction (PSI) 03/2013 requires an ambulance to be called automatically as a mandatory contingency response upon a code blue or red being called, and the directs staff to await updates from the scene. This PSI is not currently being followed at HMP Guys Marsh.
xvii. Frazer did not have any contact with his family whilst at HMP Guys Marsh and when his mother was told of his death, she thought it was a mistake as she thought he was still at HMP Winchester. She had been writing to Frazer at HMP Winchester through the email a prisoner service. There was no evidence her correspondence had reached Frazer. Email a prisoner is based on the person in the community who wants to contact the prisoner, entering the prisoner’s location in the prison estate, rather than their unique prison number. If the location is wrong or the prisoner has been moved, the prisoner will not receive the contact.
xviii. Frazer told prison staff during his induction at HMP Guys Marsh and the ACCT assessment that he was in contact with his family and he used his parents for support. Familial contact can be a key protective factor in the management of a person’s mental health. In the personal information section of Frazer’s NOMIS records, he was recorded as having no next of kin. There is no record the contact details of his next of kin were discussed with him. This evidences missed opportunities to involve Frazer’s family in his care and management prior to his death.
xix. Evidence was given that at the time if there was no next of kin recorded for a prisoner at HMP Guys Marsh a monthly report would reveal this and prisoners would be spoken to about this. There is no record Frazer was spoken to about this and it did not appear from the prison there was a clear process as to how next of kin is detailed or checked.
2. I have concerns with regard to the following: i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital.
ii. There is a lack of NHS guidance, and joint guidance with HMPPS, on the identification, management, and treatment of someone with self neglect in the prison setting.
iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
iv. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another prison.
v. There is a lack of national specification in respect of prison healthcare units.
vi. There is lack of national guidance for both senior management and operational prison staff in relation to the handover of a prisoner in advance of their transfer, not specific to, but especially those with complex needs, when transferring between prisons.
vii. The lack of ACCT quality assurance, or audit, between day 7 of the ACCT and the post closure review.
viii. There is lack of automatic flagging of a missed ACCT review at HMP Guys Marsh and this could also be a national problem.
ix. Relevant individuals, such as key workers are not being invited to attend ACCT reviews at HMP Guys Marsh in line with ACCT 6 guidance.
x. The keyworker scheme is not being delivered in line with national guidance at HMP Guys Marsh.
xi. The colour of the cell doors and bedsheets at HMP Guys Marsh, and possibly at other prisons nationally, being very similar can camouflage ligatures.
xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised.
xiii. There is a lack of process regarding the recording of a prisoner’s next of kin and involvement of them at HMP Guys Marsh.
xiv. The email a prisoner system is dependant on the person wanting to contact the prisoner knowing their location, so if the prisoner is transferred to another prison and the person contacting them is not aware, contact which can be a protective factor particularly in a prisoner’s mental health care, will not be facilitated.
ii. During his placement at HMP Lewes, Frazer presented with a deterioration in his mental health and remained subject to an ACCT due to an incident of self harm, and was also under the care of the healthcare team until the point of his release on the 4th October.
iii. Following his arrival at HMP Winchester, which has a residential healthcare unit, referrals were made to the mental health team. Frazer was assessed by a psychiatrist on the 20th December 2021 who felt that he was suffering with enduring psychotic illness and required further review.
iv. On the 14th January 2022 Frazer was transferred to HMP Guys Marsh. HMP Guys Marsh does not have a healthcare unit or a 24 hour in prison healthcare provision. The healthcare team operating hours are 7.30am to 6pm daily.
v. An email was sent from the healthcare team at HMP Winchester to the healthcare team at HMP Guys Marsh with Frazer’s name and that he was a person of interest. No other handover took place between the healthcare teams or the prison staff teams.
vi. Following Frazer’s transfer, the Head of Healthcare at HMP Guys Marsh raised an inappropriate transfer investigation as the clinical opinion was that he should not have been transferred to HMP Guys Marsh. Prior to Frazer’s transfer, there had not been a discussion with the healthcare teams at HMP Winchester and Guys Marsh by the prison service to consider suitability of Frazer’s transfer in view of the fact he was in the process of being assessed, and a confirmed diagnosis being made, relating to his mental health.
vii. The Associate Medical Director for Practice Plus Group (PPG) who provided the healthcare at HMP Lewes and HMP Guys Marsh when Frazer was at those establishments, confirmed that there is no national directory that explains what healthcare facilities are available at each prison and PPG have created one internally for the prisons they provide healthcare at. It was explained that this would assist when making decisions around suitability of location within the prison estate for prisoners, given their needs. Further if there was a national directory across all prisons this would greatly assist as PPG are only 1 of the 10 different healthcare providers across 114 prisons. He gave an example that he would not know how many disability access beds or cells there are at the prisons where PPG do not provide the healthcare. He also explained that there is no national specification in relation to healthcare units.
viii. Frazer was a person with complex needs. His mental health deteriorated at HMP Guys Marsh. He would spend most of the time in his cell, he generally did not engage with staff or ACCT reviews, and there were records that he missed and secreted medication. He held delusionary beliefs that if his toilet was flushed or he watched television, his family would come to harm. His cell was in an extremely poor state, littered with rubbish, an unflushed toilet and a bucket which was used for him to urinate and defecate in. This bucket was found to be full in his cell at the time of his death. It was acknowledged by the staff at the time he was self neglecting and he was referred to the Safety Intervention Meeting (SIM) process on the 9th February 2022. The Head of Healthcare gave evidence that there was not an adequate plan between the prison and healthcare teams to manage Frazer’s self neglect.
ix. There is no national guidance on how to manage self neglect in prison. HMPPS are currently finalising a Social Care Learning Brief on Managing Self Neglect which is expected to be issued later this year, however there is no NHS guidance on this issue or joint guidance between HMPPS and NHS as to how to manage self neglect in a prison setting.
x. Frazer’s mental health deteriorated to such an extent that following an assessment on the 9th February 2022, he was deemed to require transfer to hospital under Section 47 of the Mental Health Act 1983. The second doctor assessment was carried out the following day, 10th February 2022, and an application was sent to Ravenswood House Hospital, a secure unit within Southern Health NHS Foundation Trust on the 15th February 2022. Frazer was visited by the community psychiatrist on the 25th February 2022 when it was confirmed he required transfer to hospital for full assessment and treatment. The warrant was obtained from the Ministry of Justice for the transfer on the 1st March 2022. A bed was offered to HMP Guys Marsh by the hospital on the 1st March 2022 for admission on the 3rd March 2022, however, the prison could not facilitate an escort that day. The hospital could not facilitate safe admission on Friday 4th March 2022 or over the weekend, and the transfer was arranged for Monday 7th March 2022. Frazer was told on the 3rd March 2022 he would be transferred to hospital, however the evidence indicated he was not told when. At approximately 03.15am on the 7th March 2022 Frazer was found deceased in his cell, suspended by a ligature.
xi. The ligature was made from a ripped bedsheet attached to the top corner of the cell door. The bedsheet was the same colour as the door and had not been seen prior to his death, and was therefore camouflaged. I refer to the attached photograph of the cell door which shows the ligature in place. The colour of the cell doors in each prison is directed by the Governor of the prison and not by national directive, however the same bedsheets are issued nationally across the prison estate. The similarity in colour could be a national issue and apply to other prisons.
xii. An ACCT was opened in relation to Frazer on the 15th January 2022 and remained open until his death. Between 15th January and 7th March 2022 there were 11 case reviews. The ACCT records were incomplete and inadequate. The last case review took place on 1st March 2022. The next case review was scheduled for 3rd March 2022, however this did not take place and there was no further case review prior to Frazer’s death. The evidence did not reveal why this had not taken place. As the ACCT is a paper based system, a missed case review is not automatically flagged in any way.
xiii. Since Frazer’s death there has been the implementation of the ACCT assurance process nationally which requires the ACCT paperwork to be reviewed on 3 occasions as quality assurance or audit. Firstly, between 25 and 72 hours of the ACCT being opened, secondly at day 7 of the ACCT being opened and finally at the post closure review. If a person is subject to an ACCT for a lengthy period of time, there is a gap between day 7 and the post closure review where no quality assurance is required to be undertaken.
xiv. Frazer’s key worker at HMP Guys Marsh gave evidence that in an ideal world prison officers would sit down with a prisoner for 45 minutes once a week to undertake key work as per national guidance. He explained that the 2 key work sessions he had with Frazer lasted no more than 5 minutes and were conducted on the landing outside his cell whilst other people would be walking around the wing. This was due to the fact the officer had to run the wing at the same time and he therefore explained the keywork sessions were not effective. He confirmed that the keywork sessions he undertakes now with prisoners now would probably be no more than 15 minutes. He further confirmed he was not invited to any of Frazer’s 11 ACCT case reviews and to date he has never been invited to any ACCT reviews for any prisoner at HMP Guys Marsh, even as a prisoner’s keyworker.
xv. There is inequity in the system in that if a person is deemed detainable under the Mental Health Act 1983 in the community, they will be admitted to hospital straight away. If there is no bed available in a psychiatric unit they will be placed in an acute hospital where there is monitoring and access to medical care 24 hours a day. If a person is in need of hospital care and treatment under Section 47 of the Mental Health Act 1983, there are delays in the transfer to a hospital setting. When a prisoner suffers a physical health problem they can be transferred to hospital for care by ambulance or escort. With a mental health care problem, the appropriate paperwork needs to be completed, a hospital bed found and arrangements made for transfer before a person is admitted to hospital. During this time a prisoner may be placed, as Frazer was, in a prison without a healthcare unit and without 24 hour healthcare monitoring and care. The current legal timeframe for this is within 28 days. In relation to Frazer, his transfer would have been completed 26 days after he was first assessed Several witness said this was one of the quickest transfers they had experienced.
xvi. When a code blue or code red is called at HMP Guys Marsh, evidence was given that the control room do not automatically call an ambulance and before doing so, ask questions such as is the patient conscious and breathing. Annex A of Prison Service Instruction (PSI) 03/2013 requires an ambulance to be called automatically as a mandatory contingency response upon a code blue or red being called, and the directs staff to await updates from the scene. This PSI is not currently being followed at HMP Guys Marsh.
xvii. Frazer did not have any contact with his family whilst at HMP Guys Marsh and when his mother was told of his death, she thought it was a mistake as she thought he was still at HMP Winchester. She had been writing to Frazer at HMP Winchester through the email a prisoner service. There was no evidence her correspondence had reached Frazer. Email a prisoner is based on the person in the community who wants to contact the prisoner, entering the prisoner’s location in the prison estate, rather than their unique prison number. If the location is wrong or the prisoner has been moved, the prisoner will not receive the contact.
xviii. Frazer told prison staff during his induction at HMP Guys Marsh and the ACCT assessment that he was in contact with his family and he used his parents for support. Familial contact can be a key protective factor in the management of a person’s mental health. In the personal information section of Frazer’s NOMIS records, he was recorded as having no next of kin. There is no record the contact details of his next of kin were discussed with him. This evidences missed opportunities to involve Frazer’s family in his care and management prior to his death.
xix. Evidence was given that at the time if there was no next of kin recorded for a prisoner at HMP Guys Marsh a monthly report would reveal this and prisoners would be spoken to about this. There is no record Frazer was spoken to about this and it did not appear from the prison there was a clear process as to how next of kin is detailed or checked.
2. I have concerns with regard to the following: i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital.
ii. There is a lack of NHS guidance, and joint guidance with HMPPS, on the identification, management, and treatment of someone with self neglect in the prison setting.
iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
iv. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another prison.
v. There is a lack of national specification in respect of prison healthcare units.
vi. There is lack of national guidance for both senior management and operational prison staff in relation to the handover of a prisoner in advance of their transfer, not specific to, but especially those with complex needs, when transferring between prisons.
vii. The lack of ACCT quality assurance, or audit, between day 7 of the ACCT and the post closure review.
viii. There is lack of automatic flagging of a missed ACCT review at HMP Guys Marsh and this could also be a national problem.
ix. Relevant individuals, such as key workers are not being invited to attend ACCT reviews at HMP Guys Marsh in line with ACCT 6 guidance.
x. The keyworker scheme is not being delivered in line with national guidance at HMP Guys Marsh.
xi. The colour of the cell doors and bedsheets at HMP Guys Marsh, and possibly at other prisons nationally, being very similar can camouflage ligatures.
xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised.
xiii. There is a lack of process regarding the recording of a prisoner’s next of kin and involvement of them at HMP Guys Marsh.
xiv. The email a prisoner system is dependant on the person wanting to contact the prisoner knowing their location, so if the prisoner is transferred to another prison and the person contacting them is not aware, contact which can be a protective factor particularly in a prisoner’s mental health care, will not be facilitated.
Responses
Action Taken
NHS England is responding to 'The Long Wait' HMIP report, and is working with HMPPS nationally and regionally to support the ACCT process. HMP Guys Marsh issued guidance to healthcare staff and relevant training was provided to induction and reception staff who conduct first night interviews. NHS England South West region supported the development of e-learning training for healthcare staff on safeguarding in secure and detained settings. (AI summary)
NHS England is responding to 'The Long Wait' HMIP report, and is working with HMPPS nationally and regionally to support the ACCT process. HMP Guys Marsh issued guidance to healthcare staff and relevant training was provided to induction and reception staff who conduct first night interviews. NHS England South West region supported the development of e-learning training for healthcare staff on safeguarding in secure and detained settings. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Frazer Charlie Williams who died on 7 March 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 31 May 2024 concerning the death of Frazer Charlie Williams on 7 March 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Frazer’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Frazer’s care have been listened to and reflected upon.
I have responded to your matters of concern which are relevant to NHS England below.
1. There is inequity within the system of the treatment of a person with mental illness in the prison setting, compared to an individual in the community, since in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission. In prison however, there are delays in transferring a prisoner in the same situation to hospital.
I would like to reassure you that NHS England consistently strives for equality in mental health healthcare provision. To address the specific concerns about Frazer’s care, there are several cross party workstreams underway.
In February 2024, His Majesty’s Inspectorate of Prisons (HMIP) published “The Long Wait”, a thematic review of delays in the transfer of mentally unwell prisoners, which identified several concerns. The concerns include areas such as length of time to transfer, hospital availability, information sharing and early identification of needs. NHS England’s Health and Justice, Specialist Commissioning and Adult Mental Health Teams, the Department of Health and Social Care (DHSC) and His Majesty’s Prison and Probation Service (HMPPS) are in the process of directly responding to the concerns highlighted in this review. This response is due to be with our National Director of Health & Justice, Armed Forces and Sexual Assault Referral Centres imminently, for approval to meet the timeframe for submission. A new clinical template for improving data collection and monitoring has been developed and is now in place, to record the referral, assessment and transfer process for prisoners and detainees, under sections 47 and 48 of the Mental Health Act (MHA) National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
24 July 2024
1983. This template is for use within the health and justice information system (HJIS) in prisons (currently SystmOne). NHS England is working to use the information generated to gather data on the timeliness of transfers, whilst also proactively working with Health and Justice commissioners to improve data quality and completeness of existing manual collection.
A review of processes, communication and information sharing around mental health concerns is also underway and will be completed by February 2025. This review is calling “Health and Justice Mental Health Pathway”. Work on the development of a Mental Health Pathway aims to:
• Ensure from a patient perspective the pathway is robust, seamless, individualised, and responsive to a person’s needs and requirements.
• Provide people with mental health concerns consistent, high-quality advice/treatment/support across all Health and Justice services.
• Reduce reoffending and improve health outcomes by addressing the underlying mental health and associated vulnerability issues. To achieve this, NHS England will:
• Clarify the current mental health provision within each Health and Justice service.
• Identify and build on best practice.
• Identify and understand dependencies between Health and Justice services and other parts of the pathway.
• Understand where we are now and develop a proposed pathway for engagement.
• Develop a pathway programme plan based on identified gaps and key priorities. To support this work, a series of online workshops are planned throughout August 2024 for subject matter experts to come together and share knowledge and experience in areas such as governance, transfer and remission, and information sharing.
2. There is a lack of NHS guidance, and joint guidance with HMPPS, on the identification, management, and treatment of someone with self-neglect in the prison setting.
It is clear in this case that information sharing, and general communication, could have been stronger. NHS England is committed to improving information sharing between agencies and promoting better joint working, to improve outcomes for people with mental health needs, and the Prison Mental Health Service Specification (March 2018) covers these elements: service-specification-mental-health-for-prisons-in-england-
2.pdf.
This service specification links directly the Royal College of Psychiatrists’ (RCPsych) guidance on Standards for Prison Mental Health Services (September 2023) which provides clear guidance for mental healthcare provision. The regional NHS England Health and Justice commissioners include these specifications as a link into the Prison Mental Health Service Specification. The commissioners monitor the providers’
progress against the agreed specification. Regular NHS England national meetings are held with the regional commissioners, and this will be raised this at the national meetings.
3. There are two parts to this next concern, which I have separated as follows:
i. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold.
NHS England suggests that this would be for HMPPS to respond to, however we will continue to work with HMPPS on any proposed actions requiring healthcare input.
ii. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
It is clear that communication between clinicians in Frazer’s case fell below the expected standard. It is also a concern whether a receiving prison can manage and support significant mental health concerns such as those experienced by Frazer.
As explained above, the pathway work currently underway will review issues around consistency of clinical care, information sharing and communication, not only within NHS England but across the dependent and aligned services. The output from this work should address the concerns highlighted.
4. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another prison.
NHS England is continually striving to improve communication, information sharing and handover of information between the custodial services. In addition to the Mental Health Pathway work, each Health & Justice regional commissioner manages the contract and monitors the services against the agreed specification.
There is a National Partnership Agreement (NPA) in place which sets the agreement between DHSC, HMPPS, the Ministry of Justice (MOJ), NHS England and the United Kingdom Health Security Agency (UKHSA), which supports and strengthens partnership working across agencies.
The NPA sets out the basis of shared understanding of, and commitment to, the way in which partners will work together across prison and people - National Partnership Agreement for Health and Social Care (publishing.service.gov.uk). This is a regional
commissioner responsibility, to ensure from a health perspective that the providers are fully engaged with the partnership agreement.
HMPPS can provide a response regarding the NPA from their perspective to also commit to this.
5. There is a lack of national specification in respect of prison healthcare units. The Prison Mental Health Service Specification (March 2018), referred to above, provides clear guidance for mental healthcare provision within prisons. This will be updated and reviewed by quarter one of 2025. In the meantime, following the sad death of Frazer, NHS England will work with our commissioning teams to ensure the specifications are being followed and measures are put in place to monitor their progress. In addition to the concerns highlighted above, I note that there are also concerns at paragraphs 7 (vii), 8 (viii) and 9 (ix) of your Report around:
7. The lack of Assessment Care in Custody and Teamwork (ACCT) quality assurance or audit between day 7 of the ACCT and post closure review.
8. The lack of automatic flagging of a missed ACCT review at HMP Guys Marsh, which may be a national issue.
9. Relevant individuals such as key workers not being invited to attend ACCT reviews at HMP Guys Marsh, in line with ACCT 6 guidance.
The points above relating to the ACCT process (annex-to-psi-64-2011-acct_.docx (live.com) will be shared with NHS England’s regional Health and Justice commissioners, with a request that they monitor this in contract review meetings and feedback via the Health and Justice Oversight Delivery 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 the national and regional teams, with a focus on improving health outcomes and reducing variation across England.
Overall, HMPPS is responsible for, and oversees, the ACCT process, including delivery of effective training that is carried out at establishment level for all staff, including healthcare, and I note that HMPPS is responding independently to the concerns about ACCT in Frazer’s case.
I understand that in September 2022, the Safer Custody Team provided refresher training to healthcare staff at HMP Guys Marsh, to ensure they understand their responsibilities to identify prisoners at risk of suicide and self-harm. Further guidance supporting this was issued to ensure staff awareness of the need to notify relevant departments where concerns about a prisoner’s risk of self-harm or suicide are identified. Relevant training highlighting the importance of sharing, recording, and considering all relevant risk information has also been provided to induction and
reception staff who conduct first night interviews. HMP Guys Marsh confirms this will continue at regular intervals throughout the year.
NHS England will continue to work in partnership with HMPPS nationally and regionally to support the ACCT process.
Additionally, HMP Guys Marsh sit as a member on the Dorset Local Safeguarding Board and are therefore subject to Bournemouth and Poole and Dorset Safeguarding Boards’ guidance on self-neglect. NHS England’s South West region also supported the development of the e-learning training for healthcare staff on safeguarding in secure and detained settings: Adult Safeguarding in a Secure and Detained Setting - elearning for healthcare (e-lfh.org.uk).
I would also like to provide further assurances on 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 learnings and insights around preventable events are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 31 May 2024 concerning the death of Frazer Charlie Williams on 7 March 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Frazer’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Frazer’s care have been listened to and reflected upon.
I have responded to your matters of concern which are relevant to NHS England below.
1. There is inequity within the system of the treatment of a person with mental illness in the prison setting, compared to an individual in the community, since in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission. In prison however, there are delays in transferring a prisoner in the same situation to hospital.
I would like to reassure you that NHS England consistently strives for equality in mental health healthcare provision. To address the specific concerns about Frazer’s care, there are several cross party workstreams underway.
In February 2024, His Majesty’s Inspectorate of Prisons (HMIP) published “The Long Wait”, a thematic review of delays in the transfer of mentally unwell prisoners, which identified several concerns. The concerns include areas such as length of time to transfer, hospital availability, information sharing and early identification of needs. NHS England’s Health and Justice, Specialist Commissioning and Adult Mental Health Teams, the Department of Health and Social Care (DHSC) and His Majesty’s Prison and Probation Service (HMPPS) are in the process of directly responding to the concerns highlighted in this review. This response is due to be with our National Director of Health & Justice, Armed Forces and Sexual Assault Referral Centres imminently, for approval to meet the timeframe for submission. A new clinical template for improving data collection and monitoring has been developed and is now in place, to record the referral, assessment and transfer process for prisoners and detainees, under sections 47 and 48 of the Mental Health Act (MHA) National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
24 July 2024
1983. This template is for use within the health and justice information system (HJIS) in prisons (currently SystmOne). NHS England is working to use the information generated to gather data on the timeliness of transfers, whilst also proactively working with Health and Justice commissioners to improve data quality and completeness of existing manual collection.
A review of processes, communication and information sharing around mental health concerns is also underway and will be completed by February 2025. This review is calling “Health and Justice Mental Health Pathway”. Work on the development of a Mental Health Pathway aims to:
• Ensure from a patient perspective the pathway is robust, seamless, individualised, and responsive to a person’s needs and requirements.
• Provide people with mental health concerns consistent, high-quality advice/treatment/support across all Health and Justice services.
• Reduce reoffending and improve health outcomes by addressing the underlying mental health and associated vulnerability issues. To achieve this, NHS England will:
• Clarify the current mental health provision within each Health and Justice service.
• Identify and build on best practice.
• Identify and understand dependencies between Health and Justice services and other parts of the pathway.
• Understand where we are now and develop a proposed pathway for engagement.
• Develop a pathway programme plan based on identified gaps and key priorities. To support this work, a series of online workshops are planned throughout August 2024 for subject matter experts to come together and share knowledge and experience in areas such as governance, transfer and remission, and information sharing.
2. There is a lack of NHS guidance, and joint guidance with HMPPS, on the identification, management, and treatment of someone with self-neglect in the prison setting.
It is clear in this case that information sharing, and general communication, could have been stronger. NHS England is committed to improving information sharing between agencies and promoting better joint working, to improve outcomes for people with mental health needs, and the Prison Mental Health Service Specification (March 2018) covers these elements: service-specification-mental-health-for-prisons-in-england-
2.pdf.
This service specification links directly the Royal College of Psychiatrists’ (RCPsych) guidance on Standards for Prison Mental Health Services (September 2023) which provides clear guidance for mental healthcare provision. The regional NHS England Health and Justice commissioners include these specifications as a link into the Prison Mental Health Service Specification. The commissioners monitor the providers’
progress against the agreed specification. Regular NHS England national meetings are held with the regional commissioners, and this will be raised this at the national meetings.
3. There are two parts to this next concern, which I have separated as follows:
i. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold.
NHS England suggests that this would be for HMPPS to respond to, however we will continue to work with HMPPS on any proposed actions requiring healthcare input.
ii. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
It is clear that communication between clinicians in Frazer’s case fell below the expected standard. It is also a concern whether a receiving prison can manage and support significant mental health concerns such as those experienced by Frazer.
As explained above, the pathway work currently underway will review issues around consistency of clinical care, information sharing and communication, not only within NHS England but across the dependent and aligned services. The output from this work should address the concerns highlighted.
4. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another prison.
NHS England is continually striving to improve communication, information sharing and handover of information between the custodial services. In addition to the Mental Health Pathway work, each Health & Justice regional commissioner manages the contract and monitors the services against the agreed specification.
There is a National Partnership Agreement (NPA) in place which sets the agreement between DHSC, HMPPS, the Ministry of Justice (MOJ), NHS England and the United Kingdom Health Security Agency (UKHSA), which supports and strengthens partnership working across agencies.
The NPA sets out the basis of shared understanding of, and commitment to, the way in which partners will work together across prison and people - National Partnership Agreement for Health and Social Care (publishing.service.gov.uk). This is a regional
commissioner responsibility, to ensure from a health perspective that the providers are fully engaged with the partnership agreement.
HMPPS can provide a response regarding the NPA from their perspective to also commit to this.
5. There is a lack of national specification in respect of prison healthcare units. The Prison Mental Health Service Specification (March 2018), referred to above, provides clear guidance for mental healthcare provision within prisons. This will be updated and reviewed by quarter one of 2025. In the meantime, following the sad death of Frazer, NHS England will work with our commissioning teams to ensure the specifications are being followed and measures are put in place to monitor their progress. In addition to the concerns highlighted above, I note that there are also concerns at paragraphs 7 (vii), 8 (viii) and 9 (ix) of your Report around:
7. The lack of Assessment Care in Custody and Teamwork (ACCT) quality assurance or audit between day 7 of the ACCT and post closure review.
8. The lack of automatic flagging of a missed ACCT review at HMP Guys Marsh, which may be a national issue.
9. Relevant individuals such as key workers not being invited to attend ACCT reviews at HMP Guys Marsh, in line with ACCT 6 guidance.
The points above relating to the ACCT process (annex-to-psi-64-2011-acct_.docx (live.com) will be shared with NHS England’s regional Health and Justice commissioners, with a request that they monitor this in contract review meetings and feedback via the Health and Justice Oversight Delivery 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 the national and regional teams, with a focus on improving health outcomes and reducing variation across England.
Overall, HMPPS is responsible for, and oversees, the ACCT process, including delivery of effective training that is carried out at establishment level for all staff, including healthcare, and I note that HMPPS is responding independently to the concerns about ACCT in Frazer’s case.
I understand that in September 2022, the Safer Custody Team provided refresher training to healthcare staff at HMP Guys Marsh, to ensure they understand their responsibilities to identify prisoners at risk of suicide and self-harm. Further guidance supporting this was issued to ensure staff awareness of the need to notify relevant departments where concerns about a prisoner’s risk of self-harm or suicide are identified. Relevant training highlighting the importance of sharing, recording, and considering all relevant risk information has also been provided to induction and
reception staff who conduct first night interviews. HMP Guys Marsh confirms this will continue at regular intervals throughout the year.
NHS England will continue to work in partnership with HMPPS nationally and regionally to support the ACCT process.
Additionally, HMP Guys Marsh sit as a member on the Dorset Local Safeguarding Board and are therefore subject to Bournemouth and Poole and Dorset Safeguarding Boards’ guidance on self-neglect. NHS England’s South West region also supported the development of the e-learning training for healthcare staff on safeguarding in secure and detained settings: Adult Safeguarding in a Secure and Detained Setting - elearning for healthcare (e-lfh.org.uk).
I would also like to provide further assurances on 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 learnings and insights around preventable events are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Action Planned
Unilink will raise the issue of prisoner transfer information with the Ministry of Justice to explore the possibility of sharing relevant information to better manage and redirect communications. (AI summary)
Unilink will raise the issue of prisoner transfer information with the Ministry of Justice to explore the possibility of sharing relevant information to better manage and redirect communications. (AI summary)
View full response
Dear ,
Re: Frazer Charlie Williams – HMP Guys March. Your reference
I am writing to express our profound sadness at the tragic death of Frazer Charlie Williams while in custody at HMP Guys March. We also apologize for the delay in our response to your correspondence. This was due to our company’s year-end work around the 30th of June, which regrettably impacted our ability to reply promptly.
Following the receipt of your letter, we have conducted a thorough internal investigation regarding the email a prisoner service provided to Frazer. Our records indicate that four messages were sent to Frazer, one to HMP Lewes and three to HMP Winchester, with the last one being sent on Friday, 14th January, at HMP Winchester. It is most likely that this message was printed at HMP Winchester on 15th January or on Monday, 17th January.
However, we now understand that Frazer was moved to HMP Guys March on 14th January, and it is therefore unlikely that he received this last message. As you may know, Unilink does not have access to prison rolls or prisoner movement information for security reasons. This is expected to be known by the person contacting them. In this case neither the sender nor Unilink was aware of Frazer’s transfer and hence were unable to take any action to redirect the message or notify the sender of the situation.
We fully recognize the importance of ensuring that such communications reach their intended recipients, particularly in situations like this, and we deeply regret any distress this may have caused. To prevent similar occurrences in the future, we will raise this issue with the Ministry of Justice and explore whether there is a possibility of confidentially sharing relevant information about prisoner movements, which could help to better manage and redirect communications in a timely manner.
We are committed to doing everything within our power to improve our processes and ensure that our services function effectively and compassionately.
We remain at your disposal should you require any further information or assistance.
Re: Frazer Charlie Williams – HMP Guys March. Your reference
I am writing to express our profound sadness at the tragic death of Frazer Charlie Williams while in custody at HMP Guys March. We also apologize for the delay in our response to your correspondence. This was due to our company’s year-end work around the 30th of June, which regrettably impacted our ability to reply promptly.
Following the receipt of your letter, we have conducted a thorough internal investigation regarding the email a prisoner service provided to Frazer. Our records indicate that four messages were sent to Frazer, one to HMP Lewes and three to HMP Winchester, with the last one being sent on Friday, 14th January, at HMP Winchester. It is most likely that this message was printed at HMP Winchester on 15th January or on Monday, 17th January.
However, we now understand that Frazer was moved to HMP Guys March on 14th January, and it is therefore unlikely that he received this last message. As you may know, Unilink does not have access to prison rolls or prisoner movement information for security reasons. This is expected to be known by the person contacting them. In this case neither the sender nor Unilink was aware of Frazer’s transfer and hence were unable to take any action to redirect the message or notify the sender of the situation.
We fully recognize the importance of ensuring that such communications reach their intended recipients, particularly in situations like this, and we deeply regret any distress this may have caused. To prevent similar occurrences in the future, we will raise this issue with the Ministry of Justice and explore whether there is a possibility of confidentially sharing relevant information about prisoner movements, which could help to better manage and redirect communications in a timely manner.
We are committed to doing everything within our power to improve our processes and ensure that our services function effectively and compassionately.
We remain at your disposal should you require any further information or assistance.
Noted
The response is a cover letter forwarding the PFD response, but contains no details itself. (AI summary)
The response is a cover letter forwarding the PFD response, but contains no details itself. (AI summary)
View full response
Dear Coroner; Frazer Williams _ ref: 23542028 Please find attached the PFD response reference the death of Frazer Williams_
Action Planned
The Department of Health and Social Care acknowledges concerns about mental health treatment equity in prisons and delays in transferring mentally unwell prisoners. They mention the Mental Health Bill, which will introduce a 28-day statutory time limit for transfers from prison to hospital, and that they expect other recipients of the report to address concerns around national guidance, ACCT processes and engagement with family members. (AI summary)
The Department of Health and Social Care acknowledges concerns about mental health treatment equity in prisons and delays in transferring mentally unwell prisoners. They mention the Mental Health Bill, which will introduce a 28-day statutory time limit for transfers from prison to hospital, and that they expect other recipients of the report to address concerns around national guidance, ACCT processes and engagement with family members. (AI summary)
View full response
Dear Ms Griffin,
Thank you for your Regulation 28 report to prevent future deaths dated 31 May 2024, about the death of Frazer Charlie Williams. I am replying as the recently appointed Minister with responsibility for mental health and offender health.
Firstly, I would like to say how saddened I was to read of the circumstances of Frazer’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these matters to my attention.
I understand the concerns raised in your report over a lack of equity regarding accessing treatment for individuals with severe mental illness in prison settings; a lack of national guidance relating to a range of healthcare issues in prison settings; operational issues regarding the assessment, care in custody and teamwork (ACCT) process and engagement with prisoners’ family members.
I am aware that NHS England has now provided its response to your report, which sets out the steps it is taking to address inequity in the system for prisoners accessing treatment and responds to your concerns around the transfer of mentally unwell prisoners and the provision of healthcare in prison settings.
I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.
In addition to this, the Mental Health Bill will be introduced in this Parliamentary session. The Bill sets out vital reforms to support people with severe mental illness in the criminal justice
system with the aim of speeding up access to specialist inpatient care and ensuring that offenders and defendants with severe mental health needs are able to access appropriate and timely support in the most appropriate setting.
The reforms proposed in the Bill will speed up access to specialist inpatient care and treatment by introducing a new statutory time limit of 28 days for the transfer of patients from prison and other places of detention to hospital. This mirrors the time limit set out in the NHS England good practice guide published in 2021: Guidance for the Transfer and Remission of Adult Prisoners and Immigration Removal Centre Detainees under the Mental Health Act 1983. I hope that these reforms will help to reduce the likelihood of the issues outlined in your report from being repeated.
With regard to the other concerns you have raised around a lack of national guidance relating to a range of healthcare issues in prison settings; operational issues regarding the ACCT process and engagement with prisoners’ family members, I would expect the other recipients of your report to address these in their responses, as they are responsible for matters relating to day to day operations within prison settings. I look forward to seeing their responses and working with them where appropriate, to avoid a repetition of the horrific events of this case.
I hope this response is helpful in setting out how we plan to address some of the issues you have raised. Thank you for bringing these concerns to my attention.
Thank you for your Regulation 28 report to prevent future deaths dated 31 May 2024, about the death of Frazer Charlie Williams. I am replying as the recently appointed Minister with responsibility for mental health and offender health.
Firstly, I would like to say how saddened I was to read of the circumstances of Frazer’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these matters to my attention.
I understand the concerns raised in your report over a lack of equity regarding accessing treatment for individuals with severe mental illness in prison settings; a lack of national guidance relating to a range of healthcare issues in prison settings; operational issues regarding the assessment, care in custody and teamwork (ACCT) process and engagement with prisoners’ family members.
I am aware that NHS England has now provided its response to your report, which sets out the steps it is taking to address inequity in the system for prisoners accessing treatment and responds to your concerns around the transfer of mentally unwell prisoners and the provision of healthcare in prison settings.
I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.
In addition to this, the Mental Health Bill will be introduced in this Parliamentary session. The Bill sets out vital reforms to support people with severe mental illness in the criminal justice
system with the aim of speeding up access to specialist inpatient care and ensuring that offenders and defendants with severe mental health needs are able to access appropriate and timely support in the most appropriate setting.
The reforms proposed in the Bill will speed up access to specialist inpatient care and treatment by introducing a new statutory time limit of 28 days for the transfer of patients from prison and other places of detention to hospital. This mirrors the time limit set out in the NHS England good practice guide published in 2021: Guidance for the Transfer and Remission of Adult Prisoners and Immigration Removal Centre Detainees under the Mental Health Act 1983. I hope that these reforms will help to reduce the likelihood of the issues outlined in your report from being repeated.
With regard to the other concerns you have raised around a lack of national guidance relating to a range of healthcare issues in prison settings; operational issues regarding the ACCT process and engagement with prisoners’ family members, I would expect the other recipients of your report to address these in their responses, as they are responsible for matters relating to day to day operations within prison settings. I look forward to seeing their responses and working with them where appropriate, to avoid a repetition of the horrific events of this case.
I hope this response is helpful in setting out how we plan to address some of the issues you have raised. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
- HMP Guys Marsh
- HM Prisons and Probation Service
- NHS England
Response Status
Linked responses
4 of 5
56-Day Deadline
26 Jul 2024
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 10th March 2022, an investigation was commenced into the death of Frazer Charlie Williams, born on the 30th October 1993.
The investigation concluded at the end of the Inquest, before a jury, on the 17th May 2024.
The medical cause of death was:
Ia Ligature suspension
The conclusion of the Inquest was “Frazer Charlie Williams died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death”.
The investigation concluded at the end of the Inquest, before a jury, on the 17th May 2024.
The medical cause of death was:
Ia Ligature suspension
The conclusion of the Inquest was “Frazer Charlie Williams died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death”.
Circumstances of the Death
Frazer was found deceased on the 7th March 2022, in his cell at HMP Guys Marsh, Shaftesbury, Dorset, suspended by a ligature
I have attached to this report the Record of Inquest.
I have attached to this report the Record of Inquest.
Copies Sent To
Government Legal Department on behalf of the Ministry of Justice and HMP Guys Marsh
DAC Beachcroft LLP on behalf of Southern Health NHS Foundation Trust
CGL (Change Grow Live)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.