John Delahaye
PFD Report
Partially Responded
Ref: 2018-0388
Coroner's Concerns (AI summary)
National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.
View full coroner's concerns
1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate: “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, , was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, , was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
Responses
Action Planned
NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems; and SNOMED CT has been introduced as an alternative coding system into the prison general practice electronic medical records; SystmOne since 14 January 2019. (AI summary)
NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems; and SNOMED CT has been introduced as an alternative coding system into the prison general practice electronic medical records; SystmOne since 14 January 2019. (AI summary)
View full response
Dear Ms Brown Response to PFDlregulation 28 in relation to the death of Mr Delahaye Thank you for your Regulation 28 report relating to the death of Mr John Delahaye which we received from your office on 31 December 2018_ Please do be assured thatwe have taken your concerns and findings very seriously: We note that actions are required to be delivered by a number of agencies This response relates to the actions to be delivered by Birmingham and Solihull Mental Health NHS Trust and Birmingham Community Healthcare NHS Trust The concerns that you raised pertinent to BSMHFT and BCHT were:- "Matter 2. During the inquest it emerged that the mental health nurse who assessed Mr; Delahaye on the Znd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018,had not identified from his notes all relevant past medical conditions_ It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical bonditions itis not reliable at HMP Birmingham because conditions are not consistently given the correct 'read code Evidence from the NHS England clinical reviewer was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to the system for read coding into line with that in the community: The absence of a reliable source for quickly identifying relevant past and current medical conditions lives at risk misinformed decision making: HMP Birmingham healthcare, both BCHC and BSMHFT identify past medical conditions System1 using both read codes and a 'search' facility on System1. If a clinician (in any prison healthcare setting) has identified a medical condition and used a read code when documenting this, it will then flag the patient has medical condition within the 'Chair: Sue Davis, CBE Chief Executive; John Short Aboe; Stonewall Customer Relations Mon _ Fri, 8am 8pm Tel: 0800 953 0045 Text: 07985 883 509 DIVERSITY Email: bsmhft customerrelations@nhs net Website: www bsmhft nhs,uk CWAHPIQH "Isable bring - puts from from 8
summary and family history: However there are multiple read codes for conditions and are not used consistently across the prison healthcare system nationally System1 is a national system and is out of the local control of Birmingham and Solihull Mental Health NHS Foundation Trust: It is therefore recommended that this issue is highlighted by HM Coroner to NHS England for national resolution indeed we can see that this has been raised with NHSE as part of the same regulation 28 report BSMHFT does however recognise that it could put some additional Iocal controls in place to mitigate the risk associated with SystemOne and Read Codes and we are therefore implementing the following action as a provider of Healthcare in HMP Birmingham; The Head of Healthcare at HMP Birmingham will remind all clinical staff (including those working within BCHT) that when reviewing a patient's records for previous medical conditions that the following most be followed The clinician will check the 'summary and family section of System1 2 The clinician will check the 'quick glance' section of System1 3 The clinician will use the 'search function' to check for the medical conditions relevant to the clinical intervention are undertaking This reminder will be sent out to all staff in writing on the 1st February 2019. We will of course also work in collaboration with NHSE in terms of any national resolution to SystemOne: We would like' to thank you for drawing this matter to our attention and sincerely hope that the controls outlined above will help to prevent future deaths of this nature_ Yours sincerely JohufLort John Short CEO, Birmingham and Solihull Mental Health NHS Trust Cc: BCHC, Legalservices (BIRMINGHAM COMMUNITY HEALTHCARE NHS_ FOUNDATION TRUST) Dawn Clift, Associate Director of Governance, Birmingham and Solihull Mental Health NHS Trust Senior Solicitor; Birmingham and Solihull Mental Health NHS Trust they history' they
HM Prison & Probation Service Michael Spurr Chief Executive HM Prison & Probation Service 8uh Floor 102 Petty France London SWIH 9AJ E-mail: ceohmpps@noms gsi:gov uk Ms Emma Brown Area Coroner: Birmingham and Solihull The Coroner's Court; Birmingham B4 6NE E-mail: coroner@birmingham gov uk 13 February 2019 Dear Ms Brown; Inquest into death of John Delahaye Thank you for your Regulation 28 Report of 18 December 2018, issued following the inquest into the death of John Delahaye and addressed to NHS England; Birmingham and Solihull Mental Health Foundation Trust, Birmingham Community Healthcare NHS Trust; G4S and the Ministry of Justice. As Chief Executive Officer of Her Majesty's Prison and Probation. Service (HMPPS), am responding on behalf of the MOJ understand that the NHS Trust; Healthcare Trusts and G4S will be responding to you separately; know that you will share a copy of this response with Mr Delahaye's family and would first like to express my sincere condolences for their loss_ Every death in custody is a tragedy and the safety of those in our care is my absolute priority: am grateful to you for bringing to my attention your concerns You have raised issue of healthcare attendance at all first ACCT case reviews , and said that the the the
checklist of actions within ACCT booklet does not include a requirement to make staff aware of the first review_ PSI 24/2011 Safer Custody chapter 5 states that healthcare must be informed when an ACCT is opened; and should attend the first case review which must be held within 24 hours of opening an ACCT: In July 2018_ HMPPS issued a Learning Bulletin (ACCT Case Reviews, CAREMAPs and Levels of Conversations and Observations) to all prisons The Bulletin reminded staff that ACCT review meetings must be multi-disciplinary and must take place within the specified timescales. It further stated that that where any individual involved in the prisoner's management cannot attend the review; they must submit written contributions Following a review of ACCT we are currently in the process of piloting an updated ACCT document and revised guidance, which is clear that healthcare must attend first case review; and is expected also to attend subsequent review (and where this is not_possible to provide a written contribution): in cases in which issues of physical or mental health have been identified as relevant The pilot will run for a 4 month period from mid-February; It will be evaluated, we t0 roll out new procedure nationally in the autumn_ In June 2018 all HMP Birmingham ACCT case managers and members of healthcare staff including those from the mental health team and integrated drug services, were reminded by way of a written staff briefing that must attend all first ACCT case reviews, and any subsequent reviews where necessary Since Mr Delahaye's death, staff are now alerted at the Governing Governors daily staff meetings of the first ACCT case reviews which are scheduled for the day; and reminded of such by the communications room staff In September 2018, the establishment set up new quality assurance process by which members of the Safer Custody team check that all ACCT documents ` are completed in accordance with instructions and that,all necessary actions have been taken Since December 2018, a member of the senior leadership team has carried out a daily check of all ACCT documents, including verifying that healthcare staff did attend the first case review Your second concern is that whilst you were told at the inquest that senior staff had been advised that unlocking prisoners should include a welfare check; it was not clear how this had been communicated to the staff who were actually unlocking prisoners or how compliance would be monitored. PSI 75/2011 Residential Services, states that: there must be , clearly : understood systems in place for staff to assure themselves of the well-being of prisoners during or shortly . after unlock Since October : 2018, HMP : Birmingham has met: this requirement by the introduction of a new compliance process known as Residential Activities, Basics and Cleanliness (ABC): Since January this year; senior managers carry out weekly checks to ensure that staff are following the correct procedures_ All staff were made aware of the process by way of a staff briefing the the every and hope the they:
Thank you again for bringing these matters of concern to my attention: Please be assured that learning from the circumstances of John's tragic death will be shared more widely with colleagues across prison estate Yours sincerely M Spucr Michael Spurr the chacO
G4S Care Justice Services Soulhside 105 Victora Street 04 Sondersot Telephone: +44,(0)20 7963 3112 WWW,g4s.com Ms Emma Brown Area Coroner Birmingham Solihull The Coroner's Court; Birmingham_ B4 6NE By email: coroner@birmingham gov uk and first class post. Tuesday 12th February 2019 Dear Mrs Brown, Inquest into the death of John Delahaye Thank you for your Regulation Report dated 18 December 2018 addressed to NHS England Birmingham and' Solihull Mental Health Foundation Trust, Birmingham Community Healthcare Trust; G4S and the MOJ, Your report was written concerning the recent death of Mr John Delahaye at HMP Birmingham on 5lh March 2018, This response is sent on behalf of G4S Care and Justice Services (UK) Ltd ("G4S")- The report raises four concerns but it is noted that only the fourth concern is highlighted by you as being capable of addressed by G4S so we respond below to that concern only: You have indicated that your fourth concern is:- "On the moring of the Sth March 2018 Mr: Delahaye's cell had been unlocked at approximately 07.50. It is likely that he was already dead at this lime (and had been S0 for some hours) but he was not found because the prison custody officer who unlocked his cell did not Iook into the cell or seek any kind of acknowledgement from Mr. Delahaye: It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved & welfare check The Safer Custody Managers evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However; it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock The absence of a welfare check creates a risk that prisoner in need of life saving assistance at the time of unlock is not identified. It is acknowledged that the Inquest heard that the PCO who unlocked Mr Delahaye on 5ih March did not out a welfare check on him at that time that further; that PCO conceded that he knew he ought to have done_ position reiterated by the Head of Safer Custody. When officers first enter the employ of G4S at HMP Birmingham, they do as part of their induction training receive instruction on the process of unlocking prisoners It is explained to them that as well as unlocking prisoners, they should assure themselves that each prisoner is alive and well at that time: New recruits also undergo a period of shadowing experienced officers who will also demonstrate to them how the unlocking process is carried out and how a welfare check should be conducted. You will recall that the Inquest heard that on 20th August 2018, HMPPS took over the to running and management of HMP Birmingham for a period of six months, subject to further extension by the MOJ. instruction to staff does therefore come direct from HMPPS and not G4S at this point in time. However we can confirm that since October 2018, HMP Birmingham has met this requirement by the introduction of new compliance process known as Residential : Activities, Basics and Cleanliness (ABC) Since January this year;, senior managers have been carrying out weekly checks to ensure that staff are following the correct procedures_ AlI staff were made aware of the process by way of a staff briefings during October 2018 645 Camc and Juatice Services (UK} Limited Regielared Securing Your World BoudaskEwOE Gatoria Sieel Regisietcd Englend No. 393328 and being and and carry day day Any 6i6eu;
04 We can further confirm that when the time comes for HMPPS to 'step of HMP Birmingham_ system in place as described in the paragraph above will continue with G4S Senior Residential Managers continuing to audit that welfare checks are being carried out correctly by conducting weekly checks of staff. Yours sincerely, G4ek_ Managing Director Custodial & Detention Services G4S Care & Justice Services (UK) Limited Securing Your World The out'
NHS England Professor Stephen Powis Ms Emma Brown National Medical Director Area Coroner; Birmingham and 6th Floor; Skipton House Solihull 80 London Road Coroner's Court SEI 6LH 50 Newton Street_ Birmingham B4 6NE 8th February 2019 Dear Ms Brown Re: Report to Prevent Future Deaths (Regulation 28) concerning the death of Mr John Anthony Delahaye who died whilst ' remanded into the care of HMP Birmingham on 5 March 2018_ Thank you for your letter and Regulation 28 Report ("Report") issued on Tuesday 18 December 2018 following the inquest into the death of John Delahaye. would like to express my deep sympathy to Mr Delahaye's family: In your report you raised two concerns for NHS England; There is confusion surrounding the meaning of the following question from NHS England's national clinical template for In-Possession Risk Assessments in the Secure Estate 'Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?' 2 The read coding in SystmOne is not consistent across the prison estate to provide a reliable summary of significant past and current medical conditions to ensure consistency in care due to incorrect read codes being applied: will answer both your concerns below taking each one in turn In-Possession Risk Assessment Template In 2018 NHS England developed and rolled out a national clinical template to support the completion of in-possession (IP) risk assessments in prisons. This supports the implementation of the provider' s local ; in-possession medication : policies_ The assessment template was developed by a multidisciplinary group of stakeholders who were experienced in using Iocal in-possession risk assessments, The template aligns with national guidance on in-possession medication in prisons',2 The template was piloted successfully before it was implemented and training for all providers was commissioned by NHS England and delivered as part of the roll out process: It is the responsibility of the provider to ensure that clinicians using the assessment template understand how to use it effectively and that it is used in line with their local in- National Prescribing Centre 2004 "In-possession medication" link RPS 2017 "Professional Standards for Medicines Optimisation in Secure Environments 2rd Edition" link Health and high quality care for all, now and for future generations
possession medication policy The full assessment is designed to be used on initial admission into_ prison. This assessment outcome is then accessed by clinicians such as GPs who wish to review and update the status of an individuals in-possession medicines during their time in prison Clinicians have the of; completing the full assessment again thus replacing the previous assessment in full or: viewing the previous assessment information as an IP review: This means they can adjust the possession status during consultation, documenting the rationale for any change The national in-possession risk assessment has 10 questions included with weighted scoring for each question The overall score informs assessor about whether it is safe for the person to have their medication in-possession_ The score is a guide and the suggested outcome can be over-ridden by the assessor based on their clinical judgement about the person and their ability to manage their medicines independently. The question detailed in your Report (question 5 in the assessment) is focussed on unintentional non-adherence rather than intentional:non-adherenceloverdose with prescribed medicines. There is an additional question 6 in IP risk assessment (see the attached- user guide) that asks about specifically medicines overdoses_ In the last 12 months have you: a) Self-harmed or attempted suicide? b) Overdosed with medicines? The assessor . is prompted to_ pause the assessment: to check clinical notes for information about : this and the reception screen outcome which: may also have information included about risks of self-harm It is not clear from your Report whether the GP who reviewed the in-possession status for Mr Delahaye used the previous assessment information to inform the changes to_ his in-possession or whether there was a clear record. of Mr Delahaye's previous overdose of insulin that would alert clinicians to this specific risk: It is the healthcare provider's responsibility to ensure that the in-possession risk assessment us used effectively and that their in-possession policy aligns with RPS standards? and guidance about how in-possession policies should be developed On this basis NHS England does not feel that assessment tool needs to be revised_ The provider at HMP Birmingham can take local action to reduce the risk Of future harm by using local audits of in-possession risk assessments and ensuring that clinicians using the template do so in line with the User Guide, national guidance and the provider's local in-possession medication policy: In relation to this case NHS England Regional Health and Justice Commissioners (North Midlands) will monitor the in-possession. process including use of the In- Possession Risk Assessment Template through the Death in Custody. and Her Majesty's Inspectorate of Prison action plans : that have been produced at HMP Birmingham: The monitoring and oversight of the action plans and learning will also be included for review at the 2019 clinical quality visit; scheduled for the Gth June 2019, undertaken as part of the quality assurance of healthcare at HMP Birmingham; Any Health and high quality care for all, now and for future generations option the the the
further concerns relating to the use and implementation of the In-Possession Risk Assessment template will be escalated to the NHS England central team for support and review
2. SystmOne Read Codes By way of background this concern is not limited to prison healthcare and exists across all primary care general practice settings. Historically there have been two clinical coding systems in use in general practice, with all general practice systems using the same coding system causing inconsistency in coding NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems. The rollout schedule varies depending on the clinical system provider but will be complete by April 2020. SNOMED CT will provide a single clinical terminology; enabling clinical data to be exchanged accurately and consistently across all care settings. This will allow better patient care and improve how clinical data can be analysed and reported on SNOMED CT be subject to an update and management processes whereby coding can be added if it is deemed necessary but only by a central system; UK Terminology Centre There will be no ability to update or change coding at a local level SNOMED CT has been introduced as an alternative coding system into the prison general practice electronic medical records; SystmOne since 14 January 2019. In 2019 ` SNOMED CT will be the default coding system for all health and justice SystmOne_ In terms of transition to SNOMED CT;, all historic data will have a Read and SNOMED code applied via the mapping tables, the dual coding approach will support users in ensuring can revise their clinical searches as necessary NHS England: are working with NHS Digital and regional commissioners to support HJIS users during the transition phase_ hope the information above addresses the concerns you have raised within your Report and provide you with assurances that you requested: If you require any further information please do not hesitate to contact me_
summary and family history: However there are multiple read codes for conditions and are not used consistently across the prison healthcare system nationally System1 is a national system and is out of the local control of Birmingham and Solihull Mental Health NHS Foundation Trust: It is therefore recommended that this issue is highlighted by HM Coroner to NHS England for national resolution indeed we can see that this has been raised with NHSE as part of the same regulation 28 report BSMHFT does however recognise that it could put some additional Iocal controls in place to mitigate the risk associated with SystemOne and Read Codes and we are therefore implementing the following action as a provider of Healthcare in HMP Birmingham; The Head of Healthcare at HMP Birmingham will remind all clinical staff (including those working within BCHT) that when reviewing a patient's records for previous medical conditions that the following most be followed The clinician will check the 'summary and family section of System1 2 The clinician will check the 'quick glance' section of System1 3 The clinician will use the 'search function' to check for the medical conditions relevant to the clinical intervention are undertaking This reminder will be sent out to all staff in writing on the 1st February 2019. We will of course also work in collaboration with NHSE in terms of any national resolution to SystemOne: We would like' to thank you for drawing this matter to our attention and sincerely hope that the controls outlined above will help to prevent future deaths of this nature_ Yours sincerely JohufLort John Short CEO, Birmingham and Solihull Mental Health NHS Trust Cc: BCHC, Legalservices (BIRMINGHAM COMMUNITY HEALTHCARE NHS_ FOUNDATION TRUST) Dawn Clift, Associate Director of Governance, Birmingham and Solihull Mental Health NHS Trust Senior Solicitor; Birmingham and Solihull Mental Health NHS Trust they history' they
HM Prison & Probation Service Michael Spurr Chief Executive HM Prison & Probation Service 8uh Floor 102 Petty France London SWIH 9AJ E-mail: ceohmpps@noms gsi:gov uk Ms Emma Brown Area Coroner: Birmingham and Solihull The Coroner's Court; Birmingham B4 6NE E-mail: coroner@birmingham gov uk 13 February 2019 Dear Ms Brown; Inquest into death of John Delahaye Thank you for your Regulation 28 Report of 18 December 2018, issued following the inquest into the death of John Delahaye and addressed to NHS England; Birmingham and Solihull Mental Health Foundation Trust, Birmingham Community Healthcare NHS Trust; G4S and the Ministry of Justice. As Chief Executive Officer of Her Majesty's Prison and Probation. Service (HMPPS), am responding on behalf of the MOJ understand that the NHS Trust; Healthcare Trusts and G4S will be responding to you separately; know that you will share a copy of this response with Mr Delahaye's family and would first like to express my sincere condolences for their loss_ Every death in custody is a tragedy and the safety of those in our care is my absolute priority: am grateful to you for bringing to my attention your concerns You have raised issue of healthcare attendance at all first ACCT case reviews , and said that the the the
checklist of actions within ACCT booklet does not include a requirement to make staff aware of the first review_ PSI 24/2011 Safer Custody chapter 5 states that healthcare must be informed when an ACCT is opened; and should attend the first case review which must be held within 24 hours of opening an ACCT: In July 2018_ HMPPS issued a Learning Bulletin (ACCT Case Reviews, CAREMAPs and Levels of Conversations and Observations) to all prisons The Bulletin reminded staff that ACCT review meetings must be multi-disciplinary and must take place within the specified timescales. It further stated that that where any individual involved in the prisoner's management cannot attend the review; they must submit written contributions Following a review of ACCT we are currently in the process of piloting an updated ACCT document and revised guidance, which is clear that healthcare must attend first case review; and is expected also to attend subsequent review (and where this is not_possible to provide a written contribution): in cases in which issues of physical or mental health have been identified as relevant The pilot will run for a 4 month period from mid-February; It will be evaluated, we t0 roll out new procedure nationally in the autumn_ In June 2018 all HMP Birmingham ACCT case managers and members of healthcare staff including those from the mental health team and integrated drug services, were reminded by way of a written staff briefing that must attend all first ACCT case reviews, and any subsequent reviews where necessary Since Mr Delahaye's death, staff are now alerted at the Governing Governors daily staff meetings of the first ACCT case reviews which are scheduled for the day; and reminded of such by the communications room staff In September 2018, the establishment set up new quality assurance process by which members of the Safer Custody team check that all ACCT documents ` are completed in accordance with instructions and that,all necessary actions have been taken Since December 2018, a member of the senior leadership team has carried out a daily check of all ACCT documents, including verifying that healthcare staff did attend the first case review Your second concern is that whilst you were told at the inquest that senior staff had been advised that unlocking prisoners should include a welfare check; it was not clear how this had been communicated to the staff who were actually unlocking prisoners or how compliance would be monitored. PSI 75/2011 Residential Services, states that: there must be , clearly : understood systems in place for staff to assure themselves of the well-being of prisoners during or shortly . after unlock Since October : 2018, HMP : Birmingham has met: this requirement by the introduction of a new compliance process known as Residential Activities, Basics and Cleanliness (ABC): Since January this year; senior managers carry out weekly checks to ensure that staff are following the correct procedures_ All staff were made aware of the process by way of a staff briefing the the every and hope the they:
Thank you again for bringing these matters of concern to my attention: Please be assured that learning from the circumstances of John's tragic death will be shared more widely with colleagues across prison estate Yours sincerely M Spucr Michael Spurr the chacO
G4S Care Justice Services Soulhside 105 Victora Street 04 Sondersot Telephone: +44,(0)20 7963 3112 WWW,g4s.com Ms Emma Brown Area Coroner Birmingham Solihull The Coroner's Court; Birmingham_ B4 6NE By email: coroner@birmingham gov uk and first class post. Tuesday 12th February 2019 Dear Mrs Brown, Inquest into the death of John Delahaye Thank you for your Regulation Report dated 18 December 2018 addressed to NHS England Birmingham and' Solihull Mental Health Foundation Trust, Birmingham Community Healthcare Trust; G4S and the MOJ, Your report was written concerning the recent death of Mr John Delahaye at HMP Birmingham on 5lh March 2018, This response is sent on behalf of G4S Care and Justice Services (UK) Ltd ("G4S")- The report raises four concerns but it is noted that only the fourth concern is highlighted by you as being capable of addressed by G4S so we respond below to that concern only: You have indicated that your fourth concern is:- "On the moring of the Sth March 2018 Mr: Delahaye's cell had been unlocked at approximately 07.50. It is likely that he was already dead at this lime (and had been S0 for some hours) but he was not found because the prison custody officer who unlocked his cell did not Iook into the cell or seek any kind of acknowledgement from Mr. Delahaye: It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved & welfare check The Safer Custody Managers evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However; it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock The absence of a welfare check creates a risk that prisoner in need of life saving assistance at the time of unlock is not identified. It is acknowledged that the Inquest heard that the PCO who unlocked Mr Delahaye on 5ih March did not out a welfare check on him at that time that further; that PCO conceded that he knew he ought to have done_ position reiterated by the Head of Safer Custody. When officers first enter the employ of G4S at HMP Birmingham, they do as part of their induction training receive instruction on the process of unlocking prisoners It is explained to them that as well as unlocking prisoners, they should assure themselves that each prisoner is alive and well at that time: New recruits also undergo a period of shadowing experienced officers who will also demonstrate to them how the unlocking process is carried out and how a welfare check should be conducted. You will recall that the Inquest heard that on 20th August 2018, HMPPS took over the to running and management of HMP Birmingham for a period of six months, subject to further extension by the MOJ. instruction to staff does therefore come direct from HMPPS and not G4S at this point in time. However we can confirm that since October 2018, HMP Birmingham has met this requirement by the introduction of new compliance process known as Residential : Activities, Basics and Cleanliness (ABC) Since January this year;, senior managers have been carrying out weekly checks to ensure that staff are following the correct procedures_ AlI staff were made aware of the process by way of a staff briefings during October 2018 645 Camc and Juatice Services (UK} Limited Regielared Securing Your World BoudaskEwOE Gatoria Sieel Regisietcd Englend No. 393328 and being and and carry day day Any 6i6eu;
04 We can further confirm that when the time comes for HMPPS to 'step of HMP Birmingham_ system in place as described in the paragraph above will continue with G4S Senior Residential Managers continuing to audit that welfare checks are being carried out correctly by conducting weekly checks of staff. Yours sincerely, G4ek_ Managing Director Custodial & Detention Services G4S Care & Justice Services (UK) Limited Securing Your World The out'
NHS England Professor Stephen Powis Ms Emma Brown National Medical Director Area Coroner; Birmingham and 6th Floor; Skipton House Solihull 80 London Road Coroner's Court SEI 6LH 50 Newton Street_ Birmingham B4 6NE 8th February 2019 Dear Ms Brown Re: Report to Prevent Future Deaths (Regulation 28) concerning the death of Mr John Anthony Delahaye who died whilst ' remanded into the care of HMP Birmingham on 5 March 2018_ Thank you for your letter and Regulation 28 Report ("Report") issued on Tuesday 18 December 2018 following the inquest into the death of John Delahaye. would like to express my deep sympathy to Mr Delahaye's family: In your report you raised two concerns for NHS England; There is confusion surrounding the meaning of the following question from NHS England's national clinical template for In-Possession Risk Assessments in the Secure Estate 'Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?' 2 The read coding in SystmOne is not consistent across the prison estate to provide a reliable summary of significant past and current medical conditions to ensure consistency in care due to incorrect read codes being applied: will answer both your concerns below taking each one in turn In-Possession Risk Assessment Template In 2018 NHS England developed and rolled out a national clinical template to support the completion of in-possession (IP) risk assessments in prisons. This supports the implementation of the provider' s local ; in-possession medication : policies_ The assessment template was developed by a multidisciplinary group of stakeholders who were experienced in using Iocal in-possession risk assessments, The template aligns with national guidance on in-possession medication in prisons',2 The template was piloted successfully before it was implemented and training for all providers was commissioned by NHS England and delivered as part of the roll out process: It is the responsibility of the provider to ensure that clinicians using the assessment template understand how to use it effectively and that it is used in line with their local in- National Prescribing Centre 2004 "In-possession medication" link RPS 2017 "Professional Standards for Medicines Optimisation in Secure Environments 2rd Edition" link Health and high quality care for all, now and for future generations
possession medication policy The full assessment is designed to be used on initial admission into_ prison. This assessment outcome is then accessed by clinicians such as GPs who wish to review and update the status of an individuals in-possession medicines during their time in prison Clinicians have the of; completing the full assessment again thus replacing the previous assessment in full or: viewing the previous assessment information as an IP review: This means they can adjust the possession status during consultation, documenting the rationale for any change The national in-possession risk assessment has 10 questions included with weighted scoring for each question The overall score informs assessor about whether it is safe for the person to have their medication in-possession_ The score is a guide and the suggested outcome can be over-ridden by the assessor based on their clinical judgement about the person and their ability to manage their medicines independently. The question detailed in your Report (question 5 in the assessment) is focussed on unintentional non-adherence rather than intentional:non-adherenceloverdose with prescribed medicines. There is an additional question 6 in IP risk assessment (see the attached- user guide) that asks about specifically medicines overdoses_ In the last 12 months have you: a) Self-harmed or attempted suicide? b) Overdosed with medicines? The assessor . is prompted to_ pause the assessment: to check clinical notes for information about : this and the reception screen outcome which: may also have information included about risks of self-harm It is not clear from your Report whether the GP who reviewed the in-possession status for Mr Delahaye used the previous assessment information to inform the changes to_ his in-possession or whether there was a clear record. of Mr Delahaye's previous overdose of insulin that would alert clinicians to this specific risk: It is the healthcare provider's responsibility to ensure that the in-possession risk assessment us used effectively and that their in-possession policy aligns with RPS standards? and guidance about how in-possession policies should be developed On this basis NHS England does not feel that assessment tool needs to be revised_ The provider at HMP Birmingham can take local action to reduce the risk Of future harm by using local audits of in-possession risk assessments and ensuring that clinicians using the template do so in line with the User Guide, national guidance and the provider's local in-possession medication policy: In relation to this case NHS England Regional Health and Justice Commissioners (North Midlands) will monitor the in-possession. process including use of the In- Possession Risk Assessment Template through the Death in Custody. and Her Majesty's Inspectorate of Prison action plans : that have been produced at HMP Birmingham: The monitoring and oversight of the action plans and learning will also be included for review at the 2019 clinical quality visit; scheduled for the Gth June 2019, undertaken as part of the quality assurance of healthcare at HMP Birmingham; Any Health and high quality care for all, now and for future generations option the the the
further concerns relating to the use and implementation of the In-Possession Risk Assessment template will be escalated to the NHS England central team for support and review
2. SystmOne Read Codes By way of background this concern is not limited to prison healthcare and exists across all primary care general practice settings. Historically there have been two clinical coding systems in use in general practice, with all general practice systems using the same coding system causing inconsistency in coding NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems. The rollout schedule varies depending on the clinical system provider but will be complete by April 2020. SNOMED CT will provide a single clinical terminology; enabling clinical data to be exchanged accurately and consistently across all care settings. This will allow better patient care and improve how clinical data can be analysed and reported on SNOMED CT be subject to an update and management processes whereby coding can be added if it is deemed necessary but only by a central system; UK Terminology Centre There will be no ability to update or change coding at a local level SNOMED CT has been introduced as an alternative coding system into the prison general practice electronic medical records; SystmOne since 14 January 2019. In 2019 ` SNOMED CT will be the default coding system for all health and justice SystmOne_ In terms of transition to SNOMED CT;, all historic data will have a Read and SNOMED code applied via the mapping tables, the dual coding approach will support users in ensuring can revise their clinical searches as necessary NHS England: are working with NHS Digital and regional commissioners to support HJIS users during the transition phase_ hope the information above addresses the concerns you have raised within your Report and provide you with assurances that you requested: If you require any further information please do not hesitate to contact me_
Sent To
- Birmingham and Solihull Mental Health NHS Trust
- Birmingham Community NHS Trust
- G4S
- MOJ
- NHS England
Response Status
Linked responses
1 of 5
56-Day Deadline
12 Feb 2019
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 09/03/2018 I commenced an investigation into the death of John Anthony Delahaye. The investigation concluded at the end of an inquest on 14th December 2018. The conclusion of the inquest was that on a balance of probabilities Mr. John Delahaye deliberately took an overdose of insulin with the intention of ending his life. At the time of his death Mr. Delahaye was a remand prisoner at HMP Birmingham and it was further determined by the jury that:
i. It was not appropriate that Mr. Delahaye was discharged by the mental health team (after taking an overdose of insulin on the 31st December 2017) on the 2nd January 2018 and not reviewed again and this possibly caused or contributed to his death.
ii. There should have been involvement of mental health and/or physical healthcare in the ACCT process, the absence of which possibly caused or contributed to his death.
iii. It was not appropriate for Mr. Delahaye to have insulin in his possession and this probably caused or contributed to his death.
i. It was not appropriate that Mr. Delahaye was discharged by the mental health team (after taking an overdose of insulin on the 31st December 2017) on the 2nd January 2018 and not reviewed again and this possibly caused or contributed to his death.
ii. There should have been involvement of mental health and/or physical healthcare in the ACCT process, the absence of which possibly caused or contributed to his death.
iii. It was not appropriate for Mr. Delahaye to have insulin in his possession and this probably caused or contributed to his death.
Circumstances of the Death
Mr. Delahaye was found dead in his cell, M301, at HMP Birmingham on the 5th March 2018. As a result of post mortem examination and toxicology it was identified that his death was a result of an insulin overdose. Mr. Delahaye was a type 1 diabetic and had been given an insulin pen to keep in his possession in his cell. Mr. Delahaye had previously been admitted to City Hospital, Birmingham on the 31st December 2017 as a result of an insulin overdose. He returned to HMP Birmingham on the 1st January 2018. On the 2nd January 2018 Mr. Delahaye was reviewed by a mental health nurse who found no evidence of an acute mental illness and discharged Mr. Delahaye. At that time he stated he did not remember what had happened at the time of the overdose. On the 2nd January 2018 a primary healthcare nurse opened an Assesment, Care in Custody and Teamwork book (an ‘ACCT’), as a consequence of the initial ACCT assessment and review on the 3rd January 2018 he was referred back to the mental health team for an mental health assessment but no assessment was carried out. He remained on the ACCT book until the 17th January 2018. At no time did the mental health team have any involvement in the ACCT process, the team was invited to attend by the custodial first line manager but declined. Following his return after the overdose Mr. Delahaye had initially not been allowed to have his medication in his possession but on the 29th January 2018 a GP assessed Mr. Delahaye and determined that he was suitable to have his self-administering insulin pen in his possession. He was last issued a pen on the 3rd March and it was found empty in his cell on the 5th March 2018 indicating he had taken an overdose of between 230 and 270 units.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and I believe:
i. NHS England have the power to take such action with respect to matters 1 and 2 above;
ii. BSMHT and BCHT have the power to take such action with respect to matter 2 above;
iii. The MOJ have the power to take such action with respect to matter 3 above; and
iv. G4S and the MOJ have the power to take such action with respect to matter 4 above.
i. NHS England have the power to take such action with respect to matters 1 and 2 above;
ii. BSMHT and BCHT have the power to take such action with respect to matter 2 above;
iii. The MOJ have the power to take such action with respect to matter 3 above; and
iv. G4S and the MOJ have the power to take such action with respect to matter 4 above.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.