Jamie Bennett
PFD Report
Response Pending
Ref: 2022-0136
Coroner's Concerns (AI summary)
Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes risk inadequate patient supervision and future deaths.
View full coroner's concerns
The MATTER OF CONCERN is as follows. –
The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff . There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately
The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff . There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately
Responses
Action Taken
Practice Plus Group has updated its Naloxone disclaimer form to clarify risks of refusal and revised its information-sharing process for patients discharged from HMP Moorlands, implementing new clinical handover templates and quality assurance for discharge summaries. (AI summary)
Practice Plus Group has updated its Naloxone disclaimer form to clarify risks of refusal and revised its information-sharing process for patients discharged from HMP Moorlands, implementing new clinical handover templates and quality assurance for discharge summaries. (AI summary)
View full response
Dear Madam
The Inquest touching upon the death of Mr Jamie Lee Bennett
Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners (Investigations) Regulations 2013 dated 11th May 2022 and following the inquest touching upon the death of Mr Jamie Lee Bennett, who sadly passed away on 2nd May 2020 whilst residing at Norfolk Park Bail Hostel in Sheffield following his release from HMP Moorlands on 1st May 2020.
I would like to take the opportunity on behalf of Practice Plus Group to offer my sincere condolences to Mr Bennett’s family and friends for their loss.
This letter addresses the matters of concern insofar as they relate to Practice Plus Group.
Matter of Concern
Below are the concerns quoted in the PFD report: “There were gaps in the information provided by HMP Moorlands to Norfolk Park Bail Hostel, in particular his history of substance misuse and that Jamie had refused Naloxone. The Court heard evidence that information sharing with third parties is in line with national guidelines, but also that there should have been another report by the offender management services that would have been more detailed and would have given this information to Norfolk Park. I do feel that if Norfolk Park Bail Hostel had that information, they would have been in a better position to support Jamie during those first crucial 48 hours and that may have reduced the risk of him using substances and dying.
It is my view there should be a process by which crucial information about a patient is communicated to the Approved Premise, specifically substance misuse history, any substance misuse work, any detox or re-toxification processes undertaken, and whether the patient has accepted or refused Naloxone and any community drugs services referral. It is my view this will assist the Approved Premise to determine the level of support to be offered to a resident, especially those that are released on a Friday and will have limited support from anywhere
other than an Approved Premise during the first 48 hours.
It is my opinion there is a risk that future deaths may occur unless such a process is developed.”
Response
The following actions have now been taken to address the concerns raised.
• A reflective practice session has been held with the Healthcare team following the inquest to review our processes around Naloxone.
• Information regarding a patient being released is requested from Healthcare. Such requests can come directly from the Approved Premises, as was the case for Mr Bennett. Requests for information from the Approved Premises/Probation Service are often sent as a letter to healthcare with a very brief form attached for completion, and submission back to the requesting Approved Premises. The information requested on the form for the Approved Premises (AP) is limited information. In this case the form in question provided a section to list any current medications only. However, it is acknowledged that the covering letter sought additional information.
Following the Inquest, PPG Healthcare reflected on the type of information being requested and determined that more information should be shared. Therefore, Healthcare have drafted a more detailed template (attached for reference), which provides more specific information including, medical conditions, medication, COVID vaccinations, social services input, mental health concerns including history of self- harm, and specific equipment the patient may require, substance misuse involvement including SMS history, any current substance misuse work, any detox or re-toxification processes undertaken, whether the patient has been offered and trained for Naloxone and details of any community drugs service referrals that may have been made.
The template drafted by PPG (Appendix A) if used in future would by provide the Approved Premises with the type of information which the Coroner highlighted.
It should be noted that the template provided in the case of Jamie Lee Bennett was not created by PPG; we are not responsible for the requests and templates provided by the Approved Premises/Probation service.
• A process has been immediately implemented for managing all Approved Premises information requests: − Requests for patient information received are logged onto a spreadsheet for tracking the process. − All information/medical report requests received are scanned onto the patient record on SystmOne. − Consent to share information is signed by the patient and scanned onto the patient record (SystmOne). − The Medical Record template is completed by a manager, quality assured and shared with the requesting provider. − The completed report is scanned onto the patient record (SystmOne) providing an audit trail.
• Patients are provided with advice on discharge, where appropriate, about Naloxone. I understand this occurred in the case of Jamie Lee Bennett. However, in order for greater clarity and clinical safety, the disclaimer form for Naloxone has now been updated to make the risks of not accepting Naloxone clearer, please see Appendix B. When a
patient refuses to accept Naloxone, as in this case, they should be asked to sign the disclaimer which would be scanned onto SystmOne. Such a refusal would also be recorded on the Medical Record template to a third party as noted above.
As well as the information above I understand that an additional witness statement from the Head of Healthcare, Nicola Wraith, was provided following the conclusion of the Inquest. This also provides information on the changes made.
I hope that the above information provides you with reassurance that action has been taken, to improve the processes for sharing of information for patients being released from HMP Moorlands and the level of information shared is appropriate to the patient’s needs when released into the community.
Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Moorlands and that this extends through the gate when being released. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services.
I do hope that this letter provided the necessary reassurance sought and if I can be of any further assistance you should not hesitate to contact me directly.
The Inquest touching upon the death of Mr Jamie Lee Bennett
Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners (Investigations) Regulations 2013 dated 11th May 2022 and following the inquest touching upon the death of Mr Jamie Lee Bennett, who sadly passed away on 2nd May 2020 whilst residing at Norfolk Park Bail Hostel in Sheffield following his release from HMP Moorlands on 1st May 2020.
I would like to take the opportunity on behalf of Practice Plus Group to offer my sincere condolences to Mr Bennett’s family and friends for their loss.
This letter addresses the matters of concern insofar as they relate to Practice Plus Group.
Matter of Concern
Below are the concerns quoted in the PFD report: “There were gaps in the information provided by HMP Moorlands to Norfolk Park Bail Hostel, in particular his history of substance misuse and that Jamie had refused Naloxone. The Court heard evidence that information sharing with third parties is in line with national guidelines, but also that there should have been another report by the offender management services that would have been more detailed and would have given this information to Norfolk Park. I do feel that if Norfolk Park Bail Hostel had that information, they would have been in a better position to support Jamie during those first crucial 48 hours and that may have reduced the risk of him using substances and dying.
It is my view there should be a process by which crucial information about a patient is communicated to the Approved Premise, specifically substance misuse history, any substance misuse work, any detox or re-toxification processes undertaken, and whether the patient has accepted or refused Naloxone and any community drugs services referral. It is my view this will assist the Approved Premise to determine the level of support to be offered to a resident, especially those that are released on a Friday and will have limited support from anywhere
other than an Approved Premise during the first 48 hours.
It is my opinion there is a risk that future deaths may occur unless such a process is developed.”
Response
The following actions have now been taken to address the concerns raised.
• A reflective practice session has been held with the Healthcare team following the inquest to review our processes around Naloxone.
• Information regarding a patient being released is requested from Healthcare. Such requests can come directly from the Approved Premises, as was the case for Mr Bennett. Requests for information from the Approved Premises/Probation Service are often sent as a letter to healthcare with a very brief form attached for completion, and submission back to the requesting Approved Premises. The information requested on the form for the Approved Premises (AP) is limited information. In this case the form in question provided a section to list any current medications only. However, it is acknowledged that the covering letter sought additional information.
Following the Inquest, PPG Healthcare reflected on the type of information being requested and determined that more information should be shared. Therefore, Healthcare have drafted a more detailed template (attached for reference), which provides more specific information including, medical conditions, medication, COVID vaccinations, social services input, mental health concerns including history of self- harm, and specific equipment the patient may require, substance misuse involvement including SMS history, any current substance misuse work, any detox or re-toxification processes undertaken, whether the patient has been offered and trained for Naloxone and details of any community drugs service referrals that may have been made.
The template drafted by PPG (Appendix A) if used in future would by provide the Approved Premises with the type of information which the Coroner highlighted.
It should be noted that the template provided in the case of Jamie Lee Bennett was not created by PPG; we are not responsible for the requests and templates provided by the Approved Premises/Probation service.
• A process has been immediately implemented for managing all Approved Premises information requests: − Requests for patient information received are logged onto a spreadsheet for tracking the process. − All information/medical report requests received are scanned onto the patient record on SystmOne. − Consent to share information is signed by the patient and scanned onto the patient record (SystmOne). − The Medical Record template is completed by a manager, quality assured and shared with the requesting provider. − The completed report is scanned onto the patient record (SystmOne) providing an audit trail.
• Patients are provided with advice on discharge, where appropriate, about Naloxone. I understand this occurred in the case of Jamie Lee Bennett. However, in order for greater clarity and clinical safety, the disclaimer form for Naloxone has now been updated to make the risks of not accepting Naloxone clearer, please see Appendix B. When a
patient refuses to accept Naloxone, as in this case, they should be asked to sign the disclaimer which would be scanned onto SystmOne. Such a refusal would also be recorded on the Medical Record template to a third party as noted above.
As well as the information above I understand that an additional witness statement from the Head of Healthcare, Nicola Wraith, was provided following the conclusion of the Inquest. This also provides information on the changes made.
I hope that the above information provides you with reassurance that action has been taken, to improve the processes for sharing of information for patients being released from HMP Moorlands and the level of information shared is appropriate to the patient’s needs when released into the community.
Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Moorlands and that this extends through the gate when being released. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services.
I do hope that this letter provided the necessary reassurance sought and if I can be of any further assistance you should not hesitate to contact me directly.
Sent To
- Practice Plus Group
- The Ministry of Justice, Justice and Development Division, Litigation Group, Government Legal Department
Response Status
Linked responses
1 of 2
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 3 May 2020 an investigation commenced into the death of Jamie Lee Bennett, aged 33 years. The investigation concluded with an inquest heard between 25 April 2022 and 29 April 2022. The Coroner returned a narrative conclusion
Circumstances of the Death
Jamie Lee Bennett (“Jamie”) was born on 10 July 1986 in Sheffield
Jamie had a history of heroin and cocaine use dating back to approximately 2016. He had successfully completed a detoxification programme while serving a custodial sentence between 2017 to 2019, but had relapsed on release
On 3 September 2019 he was remanded to HMP Doncaster, testing positive for various substances. On 20 September 2019 he was transferred to HMP Moorlands where he remained until he was executively released on 1 May 2020. During his time at HMP Moorlands he refrained from using illicit substances and was not prescribed methadone
On 1 May 2020 he was released from HMP Moorlands to be accommodated at Norfolk Park Bail Hostel in Sheffield
On 2 May 2020 at 1.35pm Jamie was found unresponsive in his room at Norfolk Park Bail Hostel. He was pronounced deceased by paramedics
The medical cause of death at post mortem examination was: 1a. Heroin and cocaine use
The narrative conclusion given was as follows:
On 1 May 2020 Jamie Lee Bennett was executively released from HMP Moorland. He had been abstinent from drugs and methadone therapy for a period of approximately eight months. As such he was at an increased risk of overdose due to a reduced tolerance
There was a failure to formally consider re-toxification with Methadone during his release planning. It cannot be said that this caused or contributed to his death
There was a failure to follow the Local Operating Policy for Take Home Naloxone. Jamie Lee Bennett declined Naloxone and signed confirmation of this refusal was not obtained in line with the policy. It cannot be said that this caused or contributed to his death
Jamie Lee Bennett was released to Norfolk Park Bail Hostel on Norfolk Road in Sheffield where he was inducted
Due to the Exceptional Delivery Model in place in light of the Covid-19 pandemic, Jamie Lee Bennett was not offered a face-to-face appointment with his probation officer on the day of his release, room searches and drug testing were not being conducted at Norfolk Park Bail Hostel and there was no access to a substance misuse team on site
This reduced support along with the failure to provide Norfolk Park Bail Hostel with information on release about Jamie Lee Bennett’s previous substance misuse, his detoxication history, and that he had refused Naloxone, in addition to the failure to provide the community substance misuse team with his release date resulted in Norfolk Park Bail Hostel not having the opportunity to provide additional support
Had that additional support been put in place in the days immediately after his release it may have reduced the risk of him using substances and dying as a result
Jamie Lee Bennett was last seen on CCTV returning to his room at 1.01am on 2 May 2020
There was a failure to conduct the 7am welfare and curfew check in accordance with procedure in that Jamie was not roused, and it was not confirmed he was breathing. This failure was caused by a lack of training and understanding by staff as to what was expected of them during this check
There was a failure to conduct the 12pm welfare check in accordance with procedure in that the check was not carried out until 1.35pm after concerns were raised for his welfare by his family and another resident. That failure was caused by a lack of training and understanding by staff as to what was expected of them with regard to the timing of this check
At 1.35pm Jamie Lee Bennett was found unresponsive in bed. There was a delay in calling the emergency services which was caused by the lack of first aid training and staff not being in possession of radio equipment
It cannot be said what time Jamie Lee Bennett died as such, it cannot be said the failings in those checks and the delay in calling the emergency services caused or contributed to his death
Jamie Lee Bennett was pronounced deceased by paramedics on 2 May 2020 after ingesting cocaine, and an amount of heroin lower than usually encountered in deaths attributed to heroin overdose
Jamie had a history of heroin and cocaine use dating back to approximately 2016. He had successfully completed a detoxification programme while serving a custodial sentence between 2017 to 2019, but had relapsed on release
On 3 September 2019 he was remanded to HMP Doncaster, testing positive for various substances. On 20 September 2019 he was transferred to HMP Moorlands where he remained until he was executively released on 1 May 2020. During his time at HMP Moorlands he refrained from using illicit substances and was not prescribed methadone
On 1 May 2020 he was released from HMP Moorlands to be accommodated at Norfolk Park Bail Hostel in Sheffield
On 2 May 2020 at 1.35pm Jamie was found unresponsive in his room at Norfolk Park Bail Hostel. He was pronounced deceased by paramedics
The medical cause of death at post mortem examination was: 1a. Heroin and cocaine use
The narrative conclusion given was as follows:
On 1 May 2020 Jamie Lee Bennett was executively released from HMP Moorland. He had been abstinent from drugs and methadone therapy for a period of approximately eight months. As such he was at an increased risk of overdose due to a reduced tolerance
There was a failure to formally consider re-toxification with Methadone during his release planning. It cannot be said that this caused or contributed to his death
There was a failure to follow the Local Operating Policy for Take Home Naloxone. Jamie Lee Bennett declined Naloxone and signed confirmation of this refusal was not obtained in line with the policy. It cannot be said that this caused or contributed to his death
Jamie Lee Bennett was released to Norfolk Park Bail Hostel on Norfolk Road in Sheffield where he was inducted
Due to the Exceptional Delivery Model in place in light of the Covid-19 pandemic, Jamie Lee Bennett was not offered a face-to-face appointment with his probation officer on the day of his release, room searches and drug testing were not being conducted at Norfolk Park Bail Hostel and there was no access to a substance misuse team on site
This reduced support along with the failure to provide Norfolk Park Bail Hostel with information on release about Jamie Lee Bennett’s previous substance misuse, his detoxication history, and that he had refused Naloxone, in addition to the failure to provide the community substance misuse team with his release date resulted in Norfolk Park Bail Hostel not having the opportunity to provide additional support
Had that additional support been put in place in the days immediately after his release it may have reduced the risk of him using substances and dying as a result
Jamie Lee Bennett was last seen on CCTV returning to his room at 1.01am on 2 May 2020
There was a failure to conduct the 7am welfare and curfew check in accordance with procedure in that Jamie was not roused, and it was not confirmed he was breathing. This failure was caused by a lack of training and understanding by staff as to what was expected of them during this check
There was a failure to conduct the 12pm welfare check in accordance with procedure in that the check was not carried out until 1.35pm after concerns were raised for his welfare by his family and another resident. That failure was caused by a lack of training and understanding by staff as to what was expected of them with regard to the timing of this check
At 1.35pm Jamie Lee Bennett was found unresponsive in bed. There was a delay in calling the emergency services which was caused by the lack of first aid training and staff not being in possession of radio equipment
It cannot be said what time Jamie Lee Bennett died as such, it cannot be said the failings in those checks and the delay in calling the emergency services caused or contributed to his death
Jamie Lee Bennett was pronounced deceased by paramedics on 2 May 2020 after ingesting cocaine, and an amount of heroin lower than usually encountered in deaths attributed to heroin overdose
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.