Colin Blackburn
PFD Report
Partially Responded
Ref: 2021-0311
Coroner's Concerns (AI summary)
Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient observations, exacerbated by high demands and inadequate training, leading to significant risks of suicide/self-harm.
View full coroner's concerns
The The days taking
: : _ The Record of Inquest has recorded 14 separate failings in respect of Mr; Blackburn's ACCT document and his risk of suicidelself-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19; (b) that no entries were made on the Care Map until 26.6.19; that no triggers or warning signs have been entered on the ACCT's inside cover; that no ACCT Case Manager was assigned until 26.6.19; that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; that those conducting ACCT Case Reviews did not familiarize themselves sufficiently with the ACCT document beforehand; that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; that the first ligature incident on 2.7.19 was not documented on Mr: Blackburn's NOMIS record; that no ACCT Case Review took place after the first ligature incident on 2.7.19; that there was no ACCT Case Review immediately before Mr: Blackburn'$ transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr: Blackburn's NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. heard evidence that: These issues arose because prison staff had so many demands on their time, mainly due to number of prisoners they had to deal with; Since then; the population of the prison has reduced, and more new staff have been taken on; New systems have been in place regarding the management of ACCT document; the training for which was suspended during the Covid-19 pandemic; and A new version of the ACCT document was implemented in July this year; training for which has been provided to roughly a third of prison and healthcare staff at the prison: am not satisfied that sufficient action has yet been taken to ensure that all members of prison staff understand their obligations in respect of prisoners who are subject to the ACCT process_ This is because: there is no evidence yet that the changes described above have led to a change in how prison staff deal with ACCT documents; and heard evidence during the inquest from a number of senior officers who, even now, found it difficult to comprehend that their involvement with Mr: Blackburn and his ACCT document fell short of an acceptable standard. put
2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn's mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post: There was a delay in that referral reaching the Mental Team, with the result that it was not opened until after Mr. Blackburn's death: Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out heard evidence from the Head of Healthcare at the prison that urgent TAG referrals can currently be made by email,; phone or on paper via internal post If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group's regional on-cali manager. received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no divert service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, are redirected to the correct pathway The paper referral system; which relies upon the internal post at the prison, is still in place although, am told, it can be stopped. In my view; there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present:
: : _ The Record of Inquest has recorded 14 separate failings in respect of Mr; Blackburn's ACCT document and his risk of suicidelself-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19; (b) that no entries were made on the Care Map until 26.6.19; that no triggers or warning signs have been entered on the ACCT's inside cover; that no ACCT Case Manager was assigned until 26.6.19; that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; that those conducting ACCT Case Reviews did not familiarize themselves sufficiently with the ACCT document beforehand; that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; that the first ligature incident on 2.7.19 was not documented on Mr: Blackburn's NOMIS record; that no ACCT Case Review took place after the first ligature incident on 2.7.19; that there was no ACCT Case Review immediately before Mr: Blackburn'$ transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr: Blackburn's NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. heard evidence that: These issues arose because prison staff had so many demands on their time, mainly due to number of prisoners they had to deal with; Since then; the population of the prison has reduced, and more new staff have been taken on; New systems have been in place regarding the management of ACCT document; the training for which was suspended during the Covid-19 pandemic; and A new version of the ACCT document was implemented in July this year; training for which has been provided to roughly a third of prison and healthcare staff at the prison: am not satisfied that sufficient action has yet been taken to ensure that all members of prison staff understand their obligations in respect of prisoners who are subject to the ACCT process_ This is because: there is no evidence yet that the changes described above have led to a change in how prison staff deal with ACCT documents; and heard evidence during the inquest from a number of senior officers who, even now, found it difficult to comprehend that their involvement with Mr: Blackburn and his ACCT document fell short of an acceptable standard. put
2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn's mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post: There was a delay in that referral reaching the Mental Team, with the result that it was not opened until after Mr. Blackburn's death: Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out heard evidence from the Head of Healthcare at the prison that urgent TAG referrals can currently be made by email,; phone or on paper via internal post If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group's regional on-cali manager. received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no divert service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, are redirected to the correct pathway The paper referral system; which relies upon the internal post at the prison, is still in place although, am told, it can be stopped. In my view; there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present:
Responses
Action Taken
Practice Plus Group, in conjunction with MPFT, has taken several actions including ensuring all staff at HMP Hewell are aware of processes to ensure prisoners receive urgent mental health care at weekends, an Out of Office message has been added to the mental health team’s generic email inbox at weekends and an answer phone has been purchased for the mental health team. (AI summary)
Practice Plus Group, in conjunction with MPFT, has taken several actions including ensuring all staff at HMP Hewell are aware of processes to ensure prisoners receive urgent mental health care at weekends, an Out of Office message has been added to the mental health team’s generic email inbox at weekends and an answer phone has been purchased for the mental health team. (AI summary)
View full response
Dear Sir
The Inquest touching upon the death of Mr Colin Blackburn
Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners (Investigations) Regulations 2013 dated 17th September 2021 and following the inquest touching upon the death of Mr Colin Blackburn, who sadly passed away at HMP Hewell on 6th July 2019.
I would like to take the opportunity on behalf of Practice Plus Group to offer my sincere condolences to Mr Blackburn’s family and friends for their loss.
This letter addresses the matters of concern insofar as they relate to Practice Plus Group.
Practice Plus Group is the main provider of healthcare services at HMP Hewell. There is a sub- contracting arrangement in place with Midlands Partnership NHS Foundation Trust (‘MPFT’) in respect of the provision of mental health services. The Regulation 28 report was not addressed to MPFT although it has had sight of your report. This response has been prepared with the input of members of staff working for MPFT at HMP Hewell. In the event that there are any further specific operational queries relating to the mental health provision at HMP Hewell, I respectfully request that such queries be directed to MPFT.
Matter of Concern
“On 4.8.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team [sic], with the result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out. I heard evidence from the Head of Healthcare at the prison that urgent TAG referrals can currently be made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager.
I received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no diver service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway.
The paper referral system, which relies upon the internal post at the prison, is still in place although, I am told, it can be stopped.
In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self- harm which he may present.”
Response
The following actions have now been taken to address the concern raised.
1. The end date for the acceptance of paper referrals is 31st October 2021. From 1st November 2021, paper TAGs (Threshold Assessment Grid)1 will cease to be an option for referrals to the mental health team. The reason as to why this process could not immediately be stopped is to allow for the transition from paper to paperless (and the communication thereof) without incurring the additional risk of patients’ referrals being missed. In this interim period paper TAGs are being accepted by the mental health team, however, the individual who sends the TAG referral is then being asked to provide their email address to which the electronic TAG is being sent along with guidance as to how to use it, for their future reference, beyond 31st October 2021.
2. As part of this transition, posters have also been created to explain the process of making electronic TAG referrals. These are now on display (laminated, A3 size) throughout the prison. I enclose a copy of the poster with this response for your information. This work has been undertaken in conjunction with the Prison’s Health & wellbeing Governor.
3. Additionally, the posters referenced above confirm the following:-
a. The operational times for the mental health team;
b. The generic email address for the mental health team;
c. That all referrals must be sent electronically to that generic email address;
d. That the out of hours service to be provided using the primary healthcare team as a gateway.
4. This same notice has also been sent via global email to all prison staff by the Governor’s office.
5. All members of the mental health team have now added the following text to their email signatures:-
1 A TAG is a short, quickly completed assessment of the severity of an individual’s mental health problems. The scores range from none (no problem in that particular domain) to either severe or very severe. In each domain, the person completing the assessment simply ticks the statement that best applies to the individual who is being assessed.
Please reply to our generic email mpft.inclusion.hewell@mpft.nhs.net The Mental Health and Psychosocial Team at HMP Hewell is a Monday to Friday 9am - 5pm service. MPFT operate an urgent care provision at weekends, our primary care colleagues can escalate your concern via PPG on-call manager if required, please call on 01527 785138.
This implementation was carried out immediately further to the conclusion of the inquest touching upon the death of Mr Blackburn. In addition, all members of the mental health team turn on an Out of Office message every evening, as well as weekends.
6. An out of office response has been added to the mental health team’s generic email inbox at weekends, and is managed by the MPFT Administrator.
7. As an alternative to the electronic referral route for such times when a prison staff member may not have immediate access to a computer, an answer phone has been purchased for the mental health team and has been in utilisation since 13th October
2021. Whilst those incoming messages will be recorded, the voicemail auto-message will be the same as the generic email out of office response (as above). The email signatures of all members of staff within the mental health team display the generic phone number, which reaches this phone (which now carries a voicemail facility). This ensures that irrespective of whether a member of the mental health team is away from his/her desk, the incoming call will be received by the admin team, for logging and forwarding as appropriate.
I hope that the above information provides you with reassurance that action has been taken, specifically to ensure that all staff at HMP Hewell are aware of the processes in place to ensure that prisoners receive urgent mental health care at weekends, if the need arises.
Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Hewell. We will also ensure that the lessons learnt as a result of this inquest are implemented not only at HMP Hewell but 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 Colin Blackburn
Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners (Investigations) Regulations 2013 dated 17th September 2021 and following the inquest touching upon the death of Mr Colin Blackburn, who sadly passed away at HMP Hewell on 6th July 2019.
I would like to take the opportunity on behalf of Practice Plus Group to offer my sincere condolences to Mr Blackburn’s family and friends for their loss.
This letter addresses the matters of concern insofar as they relate to Practice Plus Group.
Practice Plus Group is the main provider of healthcare services at HMP Hewell. There is a sub- contracting arrangement in place with Midlands Partnership NHS Foundation Trust (‘MPFT’) in respect of the provision of mental health services. The Regulation 28 report was not addressed to MPFT although it has had sight of your report. This response has been prepared with the input of members of staff working for MPFT at HMP Hewell. In the event that there are any further specific operational queries relating to the mental health provision at HMP Hewell, I respectfully request that such queries be directed to MPFT.
Matter of Concern
“On 4.8.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team [sic], with the result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out. I heard evidence from the Head of Healthcare at the prison that urgent TAG referrals can currently be made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager.
I received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no diver service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway.
The paper referral system, which relies upon the internal post at the prison, is still in place although, I am told, it can be stopped.
In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self- harm which he may present.”
Response
The following actions have now been taken to address the concern raised.
1. The end date for the acceptance of paper referrals is 31st October 2021. From 1st November 2021, paper TAGs (Threshold Assessment Grid)1 will cease to be an option for referrals to the mental health team. The reason as to why this process could not immediately be stopped is to allow for the transition from paper to paperless (and the communication thereof) without incurring the additional risk of patients’ referrals being missed. In this interim period paper TAGs are being accepted by the mental health team, however, the individual who sends the TAG referral is then being asked to provide their email address to which the electronic TAG is being sent along with guidance as to how to use it, for their future reference, beyond 31st October 2021.
2. As part of this transition, posters have also been created to explain the process of making electronic TAG referrals. These are now on display (laminated, A3 size) throughout the prison. I enclose a copy of the poster with this response for your information. This work has been undertaken in conjunction with the Prison’s Health & wellbeing Governor.
3. Additionally, the posters referenced above confirm the following:-
a. The operational times for the mental health team;
b. The generic email address for the mental health team;
c. That all referrals must be sent electronically to that generic email address;
d. That the out of hours service to be provided using the primary healthcare team as a gateway.
4. This same notice has also been sent via global email to all prison staff by the Governor’s office.
5. All members of the mental health team have now added the following text to their email signatures:-
1 A TAG is a short, quickly completed assessment of the severity of an individual’s mental health problems. The scores range from none (no problem in that particular domain) to either severe or very severe. In each domain, the person completing the assessment simply ticks the statement that best applies to the individual who is being assessed.
Please reply to our generic email mpft.inclusion.hewell@mpft.nhs.net The Mental Health and Psychosocial Team at HMP Hewell is a Monday to Friday 9am - 5pm service. MPFT operate an urgent care provision at weekends, our primary care colleagues can escalate your concern via PPG on-call manager if required, please call on 01527 785138.
This implementation was carried out immediately further to the conclusion of the inquest touching upon the death of Mr Blackburn. In addition, all members of the mental health team turn on an Out of Office message every evening, as well as weekends.
6. An out of office response has been added to the mental health team’s generic email inbox at weekends, and is managed by the MPFT Administrator.
7. As an alternative to the electronic referral route for such times when a prison staff member may not have immediate access to a computer, an answer phone has been purchased for the mental health team and has been in utilisation since 13th October
2021. Whilst those incoming messages will be recorded, the voicemail auto-message will be the same as the generic email out of office response (as above). The email signatures of all members of staff within the mental health team display the generic phone number, which reaches this phone (which now carries a voicemail facility). This ensures that irrespective of whether a member of the mental health team is away from his/her desk, the incoming call will be received by the admin team, for logging and forwarding as appropriate.
I hope that the above information provides you with reassurance that action has been taken, specifically to ensure that all staff at HMP Hewell are aware of the processes in place to ensure that prisoners receive urgent mental health care at weekends, if the need arises.
Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Hewell. We will also ensure that the lessons learnt as a result of this inquest are implemented not only at HMP Hewell but 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
- HMP Hewell
- Practice Plus Group
Response Status
Linked responses
1 of 2
56-Day Deadline
12 Nov 2021
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 11.7.19 an investigation was commenced into the death of Colin BLACKBURN, prisoner at HMP Hewell; who died at the prison on 6.7.19, being 53 years of age. This investigation concluded at the end of the inquest on 16.9.21. medical cause of death was: Ia ligature suspension. conclusion of the inquest was as follows: "Colin Blackburn died as a result of deliberately suspending himself by a ligature. It is not possible to determine what his intention was at the time he did this. A failure adequately to assess Colin Blackburn's risk of suicide and/or self-harm at the case review of 4.7.19 probably caused or contributed to Mr. Blackburn's death: A failure to take sufficient action to meet the risk of suicide and/or self-harm which Mr: Blackburn presented at the case review of 4.7.19 probably caused or contributed to Mr: Blackburn's death.
Circumstances of the Death
At the time of his death Mr. Blackburn had spent 15 on remand at HMP Hewell awaiting trial in respect of an offence of serious violence_ An ACCT document had been opened on the day he arrived at the prison, as he had expressed thoughts of his own life; this remained open until his death. In those 15 days, there were 3 separate incidents in which Mr: Blackburn was found with a ligature around his neck He spent some 8 days in the Inpatients Unit; initially on constant watch, after the first of those incidents. His death on 6.7.19 therefore represented the fourth occasion on which he had self-ligatured.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action by conducting an investigation into the deficiencies and failures outlined above.
Inquest Conclusion
"Colin Blackburn died as a result of deliberately suspending himself by a ligature. It is not possible to determine what his intention was at the time he did this. A failure adequately to assess Colin Blackburn's risk of suicide and/or self-harm at the case review of 4.7.19 probably caused or contributed to Mr. Blackburn's death: A failure to take sufficient action to meet the risk of suicide and/or self-harm which Mr: Blackburn presented at the case review of 4.7.19 probably caused or contributed to Mr: Blackburn's death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.