Dear Mr D M Salter

Thank you for your Regulation 28 Report dated 21 March 2019, following the inquest into the death of Mr John Wright at HMP Bullingdon.

I know that you will share a copy of this response with Mr Wright’s family, and I would like first 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.

You have raised two matters of concern: information-sharing and setting the level of observation for prisoners identified as being at risk, and I will deal with each in turn.

Ensuring that all relevant information is available and used when making decisions about risk is a key priority. As you acknowledge in your report, Care UK has taken action following this case. NHS England Commissioners, Mountain Healthcare (the healthcare providers for Thames Valley Police) and the liaison and diversion service have been informed of the process for contacting the prison healthcare team with concerns about anyone coming into HMP Bullingdon. This includes details of an email address to which Care UK staff have immediate access, and telephone contact details for the reception nurse on duty at HMP Bullingdon.

Separately, the courts that serve HMP Bullingdon and the escort contractors (GEO Amey) have been reminded that safety concerns should be recorded on the Person Escort Record and shared with reception staff at HMP Bullingdon. Clinical information should be attached in a sealed envelope clearly marked “MEDICAL IN CONFIDENCE” so that it can be read by a nurse in reception. They have also been

provided with contact numbers for the safer custody team and reception, and told that urgent matters should be raised with the orderly officer.

All staff working in reception have been reminded of the importance of sharing risk information and ensuring that it is recorded on the prisoner passport. The first night custodial manager conducts regular audits of the prisoner passports to ensure that relevant information is being recorded, and that the document is being seen and used by staff working in reception.

With regard to you second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology. In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.

All staff at HMP Bullingdon understand that the risk of suicide and self-harm is at its greatest during early days in custody. The prison receives around 4,500 new prisoners every year, with at least 70% of these presenting with at least some static risk factors. The Governor is committed to redoubling efforts to prevent the loss of life through a programme of learning. All reception and first night staff have received an enhanced briefing from the head of safer custody, and all senior officers and first night staff have received risks and triggers training from the safer custody lead for the South Central prison group. At national level, an early days in custody and transitions toolkit was launched in April 2019, which provided prisons with a range of resources to support work in this area. Thank you again for bringing these matters of concern to my attention.

Dear Sir Regulation 28 – Prevention of Future Death Report: Mr John Wright- HMP Bullingdon I am writing in response to the Regulation 28 report which you issued following the inquest touching on the death of Mr John Wright, a prisoner at HMP Bullingdon. Care UK would like to express its sincere condolences to Mr Wright’s family and friends. In your report you raised 2 issues of concern, both of which are addressed to Care UK, in its capacity a healthcare provider and to Her Majesty’s Prisons and Probation Service who will respond separately to the concerns raised. Concern 1 The first concern which I raise applies to both the prison and healthcare and relates to the receipt of information by the prison and /or healthcare about a heightened risk of self-harm/suicide for a prisoner who has yet to arrive at prison. I heard evidence that it is not uncommon for outside agencies to pass on concerns and for example, copies of relevant mental health assessments, in anticipation of the prisoner arriving at the prison in a state of heightening risk requiring help and assessment. I also heard evidence that the software system operated by healthcare (SystmOne) does not enable healthcare staff to make entries prior to the prisoner being received at reception and a prison officer opening a record on the computer and allocating a prison number. This being the case, I understand that the practice has been to email or print hard copy of the document and take it to reception. Of course information about an incoming prisoner, who is assessed at high risk of suicide, is precisely the sort of information which should not be allowed to fall through any gaps. It is high priority. An outside person or agency has considered it necessary to bring the matter to the attention of the prison or healthcare. I understand Care UK have set up a generic email address for healthcare staff in reception which may assist. Clearly this still relies on healthcare staff checking to see if emails have been received.

Response Care UK is the prime provider of health services at HMP Bullingdon. Part of this service includes the screening of all new receptions into the prison. Care UK uses SystmOne which is

an electronical clinical record system which is recommended by NHS England. A copy of your letter and our response will be shared with NHS England. It is acknowledged that there is a flow of information between Liaison and Diversion Services and Mental Health Services and on this occasion it could have been improved. To this end further work has been undertaken to ensure that the communication pathways with external partners have been strengthened. A new process flow has been developed in partnership with the Liaison and Diversion team which specifies how to contact and share risk and special care needs information of patients from Police Custody (Via Court) to HMP Bullingdon Healthcare in Reception. The new process provides a direct telephone number to the Reception nurse from 08.00 to 20.45 Monday to Friday and 08.00-17.00 on Saturdays. The process flow now advises if there is no answer via telephone, the Reception nurse should be contacted via the prison communications room who will contact the nurse via their prison radio. Outside of these times detailed above, the prison communications team can contact the senior nurse on duty. This phone call alerts the Reception nurse that a report or information is being emailed to a new secure NHS email account which Healthcare at HMP Bullingdon have set up and circulated to all reception staff. The content of the email will be accessed after the telephone call alerting the Reception nurse to its existence. The Reception nurse will reply to the email to acknowledge receipt of the email. To further support this process, healthcare administration staff will routinely check the inbox during core daytime hours of 9am to 5pm and will alert Reception staff to all emails received. . All staff, including agency staff, who work in Reception have been provided with an nhs.net email account to securely access the risk information in the email. In agreement with the Liaison and Diversion service this new system went live on 25th April 2019. The requirement of a prompt made via telephone which is clearly outlined in the new process flowchart, will provide assurance to Liaison and Diversion services that their information has been effectively communicated and received by Reception staff. A copy of the process is attached. With a view to enhancing working relationships with external agencies, Care UK is working with NHS England and has identified the healthcare providers in police custody suites and the Liaison and Diversion services, that feed into HMP Bullingdon to propose setting up quarterly telephone conference calls to highlight good practice and identify emerging concerns or issues that may impact on partnership working. Additionally, Care UK has also offered Liaison and Diversion service staff an opportunity to visit the healthcare department and Reception at HMP Bullingdon to further develop an understanding of the respective work environments. Concern 2 The second matter I wish to raise also to the prison and healthcare is in relation to the level of observations. I heard evidence that this is often a joint responsibility held by the prison and healthcare. In this case Mr Wright had been on constant watch, but a decision was taken during the reception process to step down to twice hourly observations. Given that staff may not have access to all available information in those first few hours, and the fact there will not have been an opportunity for a prisoner to be observed over a significant period of time, and the fact that a more detailed assessment

will not have taken place yet, there should in my view be some guidance for staff when reducing observations from constant watch. Response Care UK recognises that early identification of risk factors and effective management of prisoners in relation to self-harm is imperative in addressing the rising incidence of suicide. Care UK are committed to training all staff in Suicide and Self Harm awareness training (SASH) and wherever possible, participating in multi-disciplinary assessments of the management of risk. Processes to request Healthcare staff to participate in all ACCT reviews at HMP Bullingdon are now imbedded throughout the establishment and have been reinforced at joint partnership meetings. These include Healthcare staff attending the prison morning meetings where they are informed of all scheduled ACCT reviews for that day. A register of Care UK staff and all sub-contracted staff who have completed the SASH training is maintained and compliance is monitored monthly. All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached. Staff meetings are held every two weeks to continue to improve and share knowledge and lessons learned regarding the management of prisoners in custody. Currently HMPPS are providing specialist HMPPS training for both healthcare and discipline staff; “Understanding Risk: Why is Risk Risky?” and “Defensible Decision Making”, both of which seek to reinforce rational and appropriate decisions when applying the ACCT process and understanding suicide risk. Care UK are providing ASIST - Applied Suicide Intervention Skills Training, which is an internationally accredited and licensed 2-day course to all patient-facing staff to increase their confidence in identifying suicide risk. This improved learning, supported by SASH training will better inform decision making in all cases, including those cases where removal from constant watch is being considered. I trust this provides assurance that Care UK are committed to improving processes to support the safety of men coming into HMP Bullingdon and developing strong communication pathways with partner organisations in the justice sector.