Dear Mr Williams Regulation 28 Report lan James Weeks (died 21 October 2017) Thank you for your letter dated 12 March 2020, following the inquest touching the death of Ian James Weeks: recognise that this has been an extremely difficult time for Mr Weeks family and would wish to offer them my sincere condolences on behalf of the University Health Board. The Health Board has reviewed the concerns you have raised within the Regulation 28 report following the inquest: My response has been informed by senior clinical and managerial staff who are able to advise me on the arising concerns and pursue the improvements required as a result; With regards to the specific matters of concern that you raised within the Regulation 28 report, have outlined them here for ease of reference: Although it was recorded on System that Mr Weeks had recently attempted suicide in another prison shortly before his admission to HMP Cardiff no member of Healthcare staff checked the medical records and further that although the GP records which were sent to the prison confirmed that Mr Weeks was prescribed anti-depressants in the community no member of Healthcare staff noticed this and as consequence Mr Weeks was not given anti-depressants in HMP Cardiff. On re-review of Mr Weeks records, the team has advised me that he was in HMP Bristol in February 2017 and an was made during an Assessment, Care in Custody and Teamwork (ACCT) care planning review; that he had attempted suicide 2 days He had regretted it and was adamant that he would not make further Bwrd Icchyd Prllysgol Caerdydd a'r Fro YW cnm gwcllhredol Bwvrdd Icchyd Uedl Prilygol Cerdydd a'r Fra Crdin wnd Vula Unlverslly Boam thc opcrationdi name Cardllt and Vale University Loaal Heath Baard CmAm Bxrd crableathin Cymeep nou Se5ed Skhuwn byrownm cxedrebu cNmebh darl Eah Mhdd potabum Gymewm uhr ord Tha Board Necoma @rAnnAn Walth 5 Engith Wo tha Ke cukele [ sor doten knnuar Contoxn Welt eumrdto = dhy entry prior. Heakth F D4

attempts on his life_ He was not known for suicide attempts and there was nothing further recorded around this: Mr Weeks came into HMP Cardiff in August 2017 . During his first and second health screening reviews he was noted to be calm and making good eye contact with staff. He knew how to access help if he required it and reported no thoughts of suicide or self-harm: He advised staff that he had not tried to harm himself in prison or outside The team received a summary from his GP in August 2017 . It highlighted that he had been seen last in 2017 and was diagnosed with anxiety and depression_ The information provided to prison staff indicated he was advised counselling and review in one month's time. There was no evidence of prescription of antidepressants although there was comment made that Mr Weeks was open to taking antidepressants. This is in keeping with recognised treatments of mild anxiety and depression when talking therapies are first line_ 2 The Healthcare witnesses, including the Head of Healthcare, indicated that a red for suicide or self-harm would be of great value for staff who because of insufficient staff and heavy workload did not have time to review the System 1 record in any or any sufficient detail: SystmOne is designed to be a secure , centralised software solution for single shared Electronic Health Record (EHR); with modules available for multiple healthcare settings_ It contains significant amount of information and reviewing the entire record for each patient would present a significant challenge: The Summary Function would normally be used by staff due to the volume of information and amount of men being assessed due to the nature of HMP Cardiff being busy remand prison with a high tumover: There are two screenings of new individuals to the prison setting t0 aid the process of assessing their needs: The healthcare staff work in conjunction with prison staff who also have role in reviewing the SystmOne records to ensure important information is identified and shared appropriately: SystmOne has been used for many years in the prison setting and there is therefore great deal of legacy information within it, the quality of which has been variable over the course of time but on an improving trajectory: The team recognises the importance of sound clinical documentation and will ensure implement process of clinical documentation audits in 2020. In order to pursue a red system, partnership with TPP (SystmOne technology provider) , NHS England, NHS Wales Informatics Service (NWIS) and other prisons will be required as this would be a change that would affect all prisons: The clinical team from HMP Cardiff intend to raise this issue at their next All Wales Prison Healthcare Meeting which Public Health Wales and Welsh Govemnment also attend. Bwrd [echyd Pnifysool Caerdydd a*r Fro YW enw owelthredol Brryrdd Iechyd Lledl Prifyanol Caerdydd ar Fra Camdin and Vile Unlverity Hralth Bourd the operabonal nome ol Cardli und Vele Unlversity Local Heatth Board Opatert Batod onabletyn Oynttanu Stra Sahtrn brtrnn Gytttebu chli akh durk Eah Mhdd pahabu i Gye9[ Qwuunhyt oed Th Bord wekanti caTetpentot h Welth & Enaltn Wwbenur lhat w' enmnket ru dorn Conmondenc Wunrurhd lo chy May flag they flag Lau

3 Further it was considered that all System records should be reviewed when an individual is admitted into the prison and that there should be in place a process for doing so. As indicated, a large volume of information is contained within SystmOne. Existing process is for healthcare staff in the prison to undertake two screening reviews of new individuals in order to assess and plan their care: This is done in conjunction with prison staff who also review the SystmOne records and share important information. The team receive GP summary on individuals which is particularly helpful in allowing the team to review a current list of medication s0 can assess whether a continued prescription in prison in appropriate There is a difference in NHS Wales to NHS England in that men entering prison in England can register with the prison which allows their whole GP record to become available to the prison healthcare team: This is not currently in place in NHS Wales: The team has recently gained funding for an IT data specialist: Recruitment to this role will be pursued once a workforce review is complete. The post holder will have key role in progressing work with NWIS to improve IT in the prison. This work has an important part to play in assisting clinical staff in their care of men in the prison. hope that the information set out in this letter provides you with the assurance that the Health Board has fully considered the issues raised as consequence of the inquest into Mr Weeks death and continues to implement appropriate action in response