Bradley Brown
PFD Report
Partially Responded
Ref: 2018-0374
Coroner's Concerns (AI summary)
Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to healthcare records, heightening risk for vulnerable individuals.
View full coroner's concerns
In circumstances it is my statutory duty to report to you: 1 Late_transfer_of_Prisoners_between Prisons on Fridayslat a weekend puts Prisoners at increased risk of death as adequate mental healthlrisk assessments cannot be conducted. There are no mental health nurses available to assesslmonitor prisoners over the weekend, thus making late transfers unsafe_ The same concern applies, in principle, to publiclbank holidays. There are different levels of healthcare at the weekends as compared to weekdays This gives cause for concern given the inherent susceptibilities with which prisoners frequently present. Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is held in isolation within the Care and Separation Unit (CSU or 'Seg' as it is colloquially known): By virtue of the different prison regime at the weekends (increased lock up periodslisolation in cells, fewer staff on duty, reduced activities) timely risk assessment is critical in the prevention of self-harm leading to death. Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner's full healthcare record, thus substantially reducing the amount of information available to them: Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database_ There is no national guidance in relation to late transfers/cut-off' points etc. 2 Commissioning of Mental Health-Healthcare Services; As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action These issues are not unique to the Prison involved in Mr Brown's case.
Responses
Action Taken
HMP Buckley Hall has instructed governors not to accept transferred prisoners on Fridays, pending healthcare changes. First night procedures have been strengthened with 72-hour monitoring and welfare checks. Healthcare staff must notify the orderly officer if prisoners miss appointments. Staff at HMP Haverigg were reminded to confirm transfers with healthcare so records are reassigned promptly. (AI summary)
HMP Buckley Hall has instructed governors not to accept transferred prisoners on Fridays, pending healthcare changes. First night procedures have been strengthened with 72-hour monitoring and welfare checks. Healthcare staff must notify the orderly officer if prisoners miss appointments. Staff at HMP Haverigg were reminded to confirm transfers with healthcare so records are reassigned promptly. (AI summary)
View full response
Dear Ms Hashmi, Thank you for your Regulation 28 Report of 30 November 2018 following recent inquest into the death of Bradley Fraser Brown at HMP Buckley Hall on 14 August 2017 . know that you will share a copy of this response with Mr Brown's family and would like first to express my condolences for their loss death in custody is a tragedy and the safety of those in our care is my absolute priority_ You have expressed concerns about the transfer of prisoners between prisons on a Friday and at weekends and hOw this may impact on the level of care and support available to them, particularly in respect of Healthcare and Mental Health assessments. understand that NHS England will also be responding directly to your concerns in terms of their healthcare processes and will explain that the new specification for the provision of healthcare at Buckley Hall will include access to mental healthcare 7 days a week: know that you will appreciate the importance of being able to move prisoners around the estate, both to manage population pressures and to ensure that prisoners Way the Every
are located in the appropriate category of prison: Inter prison transfers currently take place from Monday and Friday in accordance with a schedule agreed with the Prison Escort Court Service (PECS): Removing Friday from the schedule would put undue pressure on the remaining four days and increase the risk of late arrivals on those Prisons are always given advance warning of these scheduled transfers and PECS establishments of their anticipated arrival times, so that arrangements can be made_ In terms of weekends, whilst there is provision at a national level for inter prison transfers to be facilitated on a Saturday or Sunday, this will only be done under exceptional circumstances and is extremely rare. Transfers generally only take place over a weekend when an emergency at one prison necessitates a move of prisoners to a different establishment: However, as a result of the concerns you have raised, the Governor at HMP Buckley Hall has instructed all Governors at the establishment that should not enter into local agreements to accept transferred prisoners on a Friday: This will be reviewed once the changes to the provision of healthcare have been embedded. In addition, range of measures has been implemented to ensure that all new arrivals receive the same level of care regardless of when the transfer takes place. First night procedures have been strengthened to ensure that all prisoners arriving at the prison are subject to a 72 period of monitoring, which includes randomly spaced welfare checks during lock up periods_ Challenge Support and Intervention Plan (CSIP) is opened for any new prisoners who have been subject to a period of segregation prior to transfer. This provides for a period of monitoring to ensure that vulnerability or violence is managed appropriately. Healthcare staff have also been instructed to notify the Orderly Officer if any prisoner misses an appointment in the early days , so that reasons for non-attendance can be followed up. If a prisoner refuses to attend, Healthcare will be informed and the actions taken recorded by prison staff. Prior to any transfer there is a requirement for Healthcare staff at the sending establishment to assess each prisoner to ensure that any health concerns recorded and communicated to the receiving prison and to confirm that the prisoner is medically fit to be moved. A notice has been issued to all staff at HMP Haverigg, which was the transferring prison in Mr Brown's case, reminding them to confirm to Healthcare staff any transfer, so that medical records are reassigned promptly in order that are immediately available when the prisoner arrives at the new establishment; Thank you again for bringing these matters of concern to my attention: will ensure that learning from this tragic incident is shared widely across the prison estate_
are located in the appropriate category of prison: Inter prison transfers currently take place from Monday and Friday in accordance with a schedule agreed with the Prison Escort Court Service (PECS): Removing Friday from the schedule would put undue pressure on the remaining four days and increase the risk of late arrivals on those Prisons are always given advance warning of these scheduled transfers and PECS establishments of their anticipated arrival times, so that arrangements can be made_ In terms of weekends, whilst there is provision at a national level for inter prison transfers to be facilitated on a Saturday or Sunday, this will only be done under exceptional circumstances and is extremely rare. Transfers generally only take place over a weekend when an emergency at one prison necessitates a move of prisoners to a different establishment: However, as a result of the concerns you have raised, the Governor at HMP Buckley Hall has instructed all Governors at the establishment that should not enter into local agreements to accept transferred prisoners on a Friday: This will be reviewed once the changes to the provision of healthcare have been embedded. In addition, range of measures has been implemented to ensure that all new arrivals receive the same level of care regardless of when the transfer takes place. First night procedures have been strengthened to ensure that all prisoners arriving at the prison are subject to a 72 period of monitoring, which includes randomly spaced welfare checks during lock up periods_ Challenge Support and Intervention Plan (CSIP) is opened for any new prisoners who have been subject to a period of segregation prior to transfer. This provides for a period of monitoring to ensure that vulnerability or violence is managed appropriately. Healthcare staff have also been instructed to notify the Orderly Officer if any prisoner misses an appointment in the early days , so that reasons for non-attendance can be followed up. If a prisoner refuses to attend, Healthcare will be informed and the actions taken recorded by prison staff. Prior to any transfer there is a requirement for Healthcare staff at the sending establishment to assess each prisoner to ensure that any health concerns recorded and communicated to the receiving prison and to confirm that the prisoner is medically fit to be moved. A notice has been issued to all staff at HMP Haverigg, which was the transferring prison in Mr Brown's case, reminding them to confirm to Healthcare staff any transfer, so that medical records are reassigned promptly in order that are immediately available when the prisoner arrives at the new establishment; Thank you again for bringing these matters of concern to my attention: will ensure that learning from this tragic incident is shared widely across the prison estate_
Sent To
- MOJ
- NHS England
Response Status
Linked responses
1 of 2
56-Day Deadline
5 Jul 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 the 16t August 2017 commenced an investigation into the death of Mr Bradley Fraser Brown. The investigation was concluded by way of inquest (sitting with a jury) on the October 2018. The jury reached a narrative conclusion; which included that the deceased had taken his own life by way of self suspension, on the balance of probabilities.
Circumstances of the Death
At the time of his death Mr Brown was a serving prisoner: He had been transferred to the prison (where he subsequently died) late on the afternoon of Friday 11" August 2017. Upon arrivval, it was too late for Healthcare t0 conduct its initial assessment A brief mental health assessment was carried out but the did not have access to Mr Brown's full records: The IMR was not transferred with Mr Brown as Healthcare at the transferring prison had not been made aware of the plan to move him: Whilst Mr Brown had a past history of paranoia and drug misuse, Mental Health Nurse's assessment did not give rise to any cause for concern: Mr Brown declined referral to the mental health team_ For clarity, he was not subject to an ACCT_ He was placed in a single occupancy cell on the induction wing: Mr Brown did not attend his first healthcare screening assessment appointments on the 12"h/13" August Over the course of the weekend, he participated in periods of association etc and did not raise any concerns_ He appeared settled but quiet On the night of the 13th August 2017 _ an Operational Support Grade Officer (OSG) was allocated to patrol to induction wing as of her duties. The first roll count was completed without issue. The OSG had no cause to visit Mr Brown's cell during the course of her shift There had been problems with the OSG's 'pegging' on the wing during the night In the early hours of the 14" August;, Prison Officers discovered the OSG asleep on duty: This was escalated to the duty manager who reprimanded her. He did not report the incident to the duty Governor and did not record the incident At around 06.30-06.45 on the morning Of the 14th August the OSG carried out the morning roll count When she checked Mr Brown's cell she noted that the observation panel had been obscured by a piece of material. She could not see Mr Brown and she did not try to vocalise with him because she heard what she believed to be a noise coming from within. She did not reportlescalate the matter. At around 07:30 the oncoming Prison Officer noted that the observation panel was blocked and attempted to speak withlsee Mr Brown. When he looked down the side of the cell door he could only see the front of him_ Suspecting something untoward had happened; he called a colleague over: When they entered the cell; they found Mr Brown suspended by ligature the light fitting: Mr Brown was cut down, CPR commenced and 'code blue' called. 31" Nurse the part from
Despite best efforts, Mr Brown could not be resuscitated and the fact of his death was confirmed by attending Paramedics later the same
Despite best efforts, Mr Brown could not be resuscitated and the fact of his death was confirmed by attending Paramedics later the same
Action Should Be Taken
In my oplnlon action should be taken to prevent future deaths and believe each of you respectively have the power to take such actlon:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.