Dear Mr Rheinberg

Re: Marlin John Burrows (DoB 13/02/1977 DoD 16/08/2022)

Thank you for highlighting your concerns following the inquest of Mr Burrows, which concluded on the 29th of April 2024. On behalf of Greater Manchester Mental Health NHS Trust, I would like to offer Mr Burrows’ family our sincere condolences for their loss.

During the inquest you heard evidence that gave rise to the following matters of concern:

(1) The existing welfare sheet lacks clarity as to its exact purpose in terms of monitoring a prisoner whose health is of concern. (2) The sheet contains little guidance in relation to its completion. (3) Entries on the sheet made by prison staff appear not to be made known to attending medical staff. (4) The nature and operation of the sheet appears not to have been the subject of joint consideration on behalf of both Prison and Healthcare.

Following the conclusion of the Inquest, , Head of Healthcare for HMP Garth has met with the Governors of HMP Garth, , to address these concerns.

Our prison partners have informed us that nationally the picture has changed. His Majesties Prison and Probation Service (HMPPS) are developing national guidance for the management of people under the influence and that this process is currently going through consultation with Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.

their recognised trade unions. This national policy will address the concerns you raised in points 1, 2 and 4.

In respect of point 3 Entries on the sheet made by prison staff appear not to be made known to attending medical staff

All Healthcare staff attending prisoners have been informed that they must request the welfare checklist document on arrival at the wing, ensuring they have read and understood the entries to inform clinical decision making. This will be evidenced by them signing the sheet to say they have reviewed the information and their entry in the clinical record will state they have reviewed the welfare checklist and communicated with prison staff as part of their clinical assessment. In addition to this, assurance checks will be completed monthly by the Primary Care Manager who will review the welfare check sheets ensuring the attending staff have reviewed and signed the sheets as part of their assessment. This will be cross referenced with the clinical record to ensure that this information was considered when undertaking the assessment.

A Standard Operating Procedure (SOP) will be co-produced with prison staff following the publication of national guidance from HMPPS for prisoners who present as under the influence. This SOP will be shared widely with colleagues across the prison. We would be happy to provide a copy of this document to your Coronial Office should you wish.

In addition, the Head of Nursing and Quality for the Health & Justice Division at GMMH will work with the Healthcare staff at HMP Garth to develop some training and awareness sessions for prison staff around the use of the welfare checklist and the associated guidance once the national policy is implemented.

Can I thank you again for bringing these matters of concern to the Trust’s attention. I hope our response has gone some way to address your concerns. If you have any further questions in relation to the Trust’s response, please do let me know.

Dear Mr Rheinberg,

Thank you for your Regulation 28 report of 30 April addressed to the Governor and Head of Healthcare at HMP Garth following the inquest into the death of Marlin Burows on 16 August 2022 at HMP Garth. I am responding as Director General of Operations for His Majesty’s Prison and Probation Service (HMPPS). I am grateful to you for granting an extension for our response.

I am aware that Greater Manchester Mental Health (GMMH) NHS Foundation Trust have responded separately and therefore my response will focus on matters within the remit of HMPPS.

I know that you will share a copy of this response with Mr Burrows’ family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

Following evidence heard at the inquest, you have raised concerns about the welfare check processes at HMP Garth, including the welfare check sheet used by staff to monitor prisoners who are suspected of being under the influence of illicit substances. I am grateful to you for bringing your concerns to my attention.

I am pleased to inform you that HMPPS is currently developing national guidance for all staff managing prisoners who are under the influence of illicit substances. The guidance has been developed by the national Substance Misuse Group with contributions from internal and external stakeholders, including from areas such as health, and safety. Its purpose is to provide structured guidance for prisons to support the development of local under the influence guidance that will ensure that there is a consistent and safe response to the management of prisoners. It is important to note that this guidance does not replace healthcare advice and in a medical emergency instructions and advice from healthcare colleagues must be followed as a priority.

The guidance is currently in the consultation stage, and while I am hopeful that this will go live by the end of the year this will be dependent on what the consultation identifies and

OFFICIAL OFFICIAL whether further changes are required. I can confirm that your concerns have been shared with the Substance Misuse Group for consideration to ensure that the guidance addresses them.

Once agreed, the guidance document will be rolled out via the regional and local drug strategy leads, and they will be responsible for developing local guidance. The Substance Misuse Group will deliver additional training and support if necessary, and through their rolling programme of support, assurance checks will be conducted to ensure that under the influence guidance has been developed and embedded at each prison.

In the meantime, I have received assurance from the Governor of HMP Garth that following the inquest meetings have been held between prison and healthcare colleagues to ensure a joined up approach going forward. Once national guidance is available, a standard operating procedure will be produced so that all prison and healthcare staff understand what they are expected to do when carrying out welfare checks on prisoners being monitored under the influence. GMMH have also committed to developing local training and awareness sessions around the use of the welfare check sheet once national guidance has been published.

I am also informed that healthcare staff now request the welfare sheet upon arrival onto wings to ensure that they have had the opportunity to review and consider entries that may inform any clinical decision making.

Thank you again for bringing your concerns to my attention. I hope that this response provides assurance that action is being taken to address your concerns.