UK Inquiry Tracker

Craig Royce

PFD Report Partially Responded Ref: 2017-0379

Date of Report 20 December 2017

Coroner Caroline Beasley-Murray

Coroner Area Essex

Response Deadline est. 9 April 2018

Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking delays in crucial assessments.

View full coroner's concerns

There is no form/template to deal with the situation of a prisoner who needs to be referred to the mental health service. Reliance upon the transfer of this vital information to Healthcare by means of a telephone conversation could be unreliable. A robust, simple documentary system is required for the communication of such important information, namely that a prisoner needs to be referred to mental health services for an assessment to be carried out by mental health services. This would be distinct from the TAG system which caters for a brief assessment to be relayed across.

Responses

Response Essex Partnership NHS Trust NHS / Health Body

20 Feb 2018

Action Taken
Since taking over prison healthcare services in 2017, Essex Partnership University NHS Foundation Trust has implemented a robust documentary system for referral of prisoners to mental health care, including widening the availability of a referral form to all prison staff. (AI summary)

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Dear Mrs Beasley-Murray am writing to set out the formal response to the Regulation 28: Report to Prevent Future Deaths, dated 20 December 2017 , which was issued following the inquest into the death of Mr Craig Royce: When Mr Royce died in December 2016, the prison healthcare service was provided by Care UK. Essex Partnership University NHS Foundation Trust (EPUT) began providing the service from May 2017 . am the Chief Executive of EPUT , but have no connection with the previous service provider. would like to begin by extending my deepest condolences to the family of Mr Royce. This has been an extremely difficult time for them_ hope this response provides them, and you; with assurance that the Trust regards the situation seriously and has taken action to address the issue raised in the report: In response to the matter of concern relating to the former provider of prison healthcare service; can confirm that since EPUT took over the service in 2017 a robust documentary system for referral of prisoners to mental health care has been put in place across the prison: A referral form had been used for some time by GPs and nurses in the prison healthcare team, but EPUT ensured the availability of this form was widened significantly: It is now used by the entire prison staff in every department and other staff associated with the care of prisoners. The form is to make a and direct referral for mental health assessment and care. In an emergency, referrals to mental health will be taken by telephone still, but MUST be followed up using the form to make a written referral. The mental health referral form is available via the prison's IT system. Paper copies are provided on all wings of the prison too. Safer Custody, a department of the prison, is responsible for ensuring these are constantly available: It is distinct from the TAG system. the used full

would like to finish by reiterating condolences to Mr Royce's family at this very sad time hope this response goes some way to providing assurance that the Trust regards their loss very seriously and has taken steps to address the issue of concern about the mental health care referral system in place under the previous provider.

Sent To

Bindmans Solicitors
Care UK
Essex Partnership NHS Trust
HM Prisons and Probation Service
Phoenix Futures

Response Status

Linked responses 1 of 5

56-Day Deadline 9 Apr 2018

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 29 December 2016 I commenced an investigation into the death of Craig David Royce. The investigation concluded at the end of the inquest on 12 December 2017. The conclusion of the inquest was:-

Craig David Royce died as a result of an accident whereby he committed a deliberate act which unexpectedly and unintentionally led to his death. We the jury believe Mr Royce’s risk of self-harm/suicide was not properly reviewed with appropriate precautions taken to manage the risk

Circumstances of the Death

Craig Royce, who was 46 years old at the time of his death, had a long history of mental health problems and he also suffered from epilepsy. On 15 August 2016 he was remanded in custody to HM Prison Chelmsford. On 26 October 2016 he was sentenced to 20 months imprisonment. During his time in custody he was subject to three ACCT processes and on the evening of 24 December 2016 he we found hanging in his cell. The medical cause of death was 1a) Hypoxic brain injury b) Suspension. After an incident of self-harm on 16 October 2016 he was placed on the second of these ACCTs and a note within the documentation reads “refer to MH”. It would appear that no referral to the mental health service was made.