Mark Doyle
PFD Report
Partially Responded
Ref: 2017-0375
Coroner's Concerns (AI summary)
Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also no mandatory first aid training for existing prison officers.
View full coroner's concerns
(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by , Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check): Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover; Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk; Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file; The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
(2) Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily record.
(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise.
(4) There is no mandatory first aid training for existing (as opposed to new) prison officers. I was informed that Orderly Officers and OSGs have / are being provided with first aid training, but I am concerned this remains a serious lacuna. I appreciate it is a nationally made resourcing decision and that it has been raised previously, but I raise it for further consideration; in light of the limited number of prison and nursing staff on duty overnight, there is a real prospect of medical emergencies arising where no trained first aider is available.
(2) Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily record.
(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise.
(4) There is no mandatory first aid training for existing (as opposed to new) prison officers. I was informed that Orderly Officers and OSGs have / are being provided with first aid training, but I am concerned this remains a serious lacuna. I appreciate it is a nationally made resourcing decision and that it has been raised previously, but I raise it for further consideration; in light of the limited number of prison and nursing staff on duty overnight, there is a real prospect of medical emergencies arising where no trained first aider is available.
Responses
Action Taken
Care UK has reflected on the inquest and reviewed healthcare processes, embedding Local Operating Procedures (LOPs) with senior management audits, to ensure relevant risks and triggers are identified and shared with the prison; additionally, prisoners admitted to the Substance Misuse Unit will remain for a minimum of two weeks, with senior manager and clinical lead reviews before any moves. (AI summary)
Care UK has reflected on the inquest and reviewed healthcare processes, embedding Local Operating Procedures (LOPs) with senior management audits, to ensure relevant risks and triggers are identified and shared with the prison; additionally, prisoners admitted to the Substance Misuse Unit will remain for a minimum of two weeks, with senior manager and clinical lead reviews before any moves. (AI summary)
View full response
Dear Madam,
Regulation 28: Prevention of Future Deaths report, Mark Anthony Doyle (died 28 March
2017)
Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK on 18 December 2017 following the inquest into the death of Mr Mark Anthony Doyle at HMP Pentonville. Care UK would like to express its condolences to Mr Doyle’s family and friends.
Care UK is the main provider of healthcare services at HMP Pentonville. I have addressed the issues you have directed to Care UK only which you have highlighted as paragraphs 5.2 and 5.3.
The matters of concerns are highlighted in bold with the response set out below each concern.
Matter of Concern 1: Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily record.
Response: Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:–
Update on C nomis – entry to be made by allocated healthcare staff Update the ACCT document and highlight any trigger points Share with the Safer Custody team via their functional mailbox SafercustodyPentonville@hmps.gsi.gov.uk.
By sharing triggers with the Safer Custody team, healthcare can ensure that the senior managers on the landings and units are updated on what information has come through to their team.
HM Assistant Coroner Heather Williams QC Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP
HMP Pentonville Healthcare Department Caledonian Road London N7 8TT
Care UK Health & Rehabilitation Services Limited - Registered in England No 10498997 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9QB
Matter of Concern 2: Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise.
Response: We agree that the system described above requires improvement. We have therefore, with immediate effect, implemented a Patient Wing Movement Assessment. This is similar system to what we have in the in-patients unit as follows.
All prisoners who are deemed necessary to be admitted to the Substance Misuse Unit will remain on the unit for a period of stabilisation and until it is deemed safe for them to be moved off this unit and to be placed on normal location. By default, prisoners should not be discharged from the in- patients unit for two weeks as a minimum. If someone needs to be moved from the unit then the senior manager and clinical lead (either a GP or Care UK employed Nurse Medical Prescriber) must review the patient’s notes and make a decision on whether or not they are fit to move. This decision and the reasons for it will be recorded in the new Assessment template in the patient’s SystmOne medical notes.
“Ward rounds” and “review meetings” will be undertaken three times a week. All patients should be discussed in the review meeting and agreement reached and whether they are suitable or not to be moved from the unit and transferred to either E wing (an overspill wing for stable Substance Misuse Service clients) or to ordinary location. This ward round should always be attended by senior clinicians including either a GP or unit clinical lead.
The discussion and outcome of the meeting will be recorded in the patient’s SystmOne notes and the decision shared with the wing officer so that they are aware of who can and cannot be moved from the unit.
We are committed to providing a high quality healthcare service at HMP Pentonville and are doing everything we can to ensure those detained there are as safe as possible and receive the best quality care. We are committed to ensuring that the lessons learnt following this inquest are not just implemented at HMP Pentonville but across Care UK’s services.
We trust that the above responses provide the information that you require but please do not hesitate to contact us if Care UK can be of any further assistance.
Yours
Regional Service Manager London & IOW prisons
On behalf of Care UK
Regulation 28: Prevention of Future Deaths report, Mark Anthony Doyle (died 28 March
2017)
Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK on 18 December 2017 following the inquest into the death of Mr Mark Anthony Doyle at HMP Pentonville. Care UK would like to express its condolences to Mr Doyle’s family and friends.
Care UK is the main provider of healthcare services at HMP Pentonville. I have addressed the issues you have directed to Care UK only which you have highlighted as paragraphs 5.2 and 5.3.
The matters of concerns are highlighted in bold with the response set out below each concern.
Matter of Concern 1: Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily record.
Response: Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:–
Update on C nomis – entry to be made by allocated healthcare staff Update the ACCT document and highlight any trigger points Share with the Safer Custody team via their functional mailbox SafercustodyPentonville@hmps.gsi.gov.uk.
By sharing triggers with the Safer Custody team, healthcare can ensure that the senior managers on the landings and units are updated on what information has come through to their team.
HM Assistant Coroner Heather Williams QC Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP
HMP Pentonville Healthcare Department Caledonian Road London N7 8TT
Care UK Health & Rehabilitation Services Limited - Registered in England No 10498997 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9QB
Matter of Concern 2: Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise.
Response: We agree that the system described above requires improvement. We have therefore, with immediate effect, implemented a Patient Wing Movement Assessment. This is similar system to what we have in the in-patients unit as follows.
All prisoners who are deemed necessary to be admitted to the Substance Misuse Unit will remain on the unit for a period of stabilisation and until it is deemed safe for them to be moved off this unit and to be placed on normal location. By default, prisoners should not be discharged from the in- patients unit for two weeks as a minimum. If someone needs to be moved from the unit then the senior manager and clinical lead (either a GP or Care UK employed Nurse Medical Prescriber) must review the patient’s notes and make a decision on whether or not they are fit to move. This decision and the reasons for it will be recorded in the new Assessment template in the patient’s SystmOne medical notes.
“Ward rounds” and “review meetings” will be undertaken three times a week. All patients should be discussed in the review meeting and agreement reached and whether they are suitable or not to be moved from the unit and transferred to either E wing (an overspill wing for stable Substance Misuse Service clients) or to ordinary location. This ward round should always be attended by senior clinicians including either a GP or unit clinical lead.
The discussion and outcome of the meeting will be recorded in the patient’s SystmOne notes and the decision shared with the wing officer so that they are aware of who can and cannot be moved from the unit.
We are committed to providing a high quality healthcare service at HMP Pentonville and are doing everything we can to ensure those detained there are as safe as possible and receive the best quality care. We are committed to ensuring that the lessons learnt following this inquest are not just implemented at HMP Pentonville but across Care UK’s services.
We trust that the above responses provide the information that you require but please do not hesitate to contact us if Care UK can be of any further assistance.
Yours
Regional Service Manager London & IOW prisons
On behalf of Care UK
Sent To
- Care UK
- HMP Pentonville
- HM Prisons and Probation Service
Response Status
Linked responses
1 of 3
56-Day Deadline
13 Feb 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 5 April 2017 an investigation was commenced into the death of Mark Anthony Doyle, aged 45 years old. The investigation concluded at the end of the inquest on 12 December 2017. The jury found that Mr Doyle died on 28 March 2017 at University College London Hospital, as a result of injuries earlier sustained when he suspended himself from the bars of his cell window at HMP Pentonville with a ligature. The jury made a narrative determination that his intention at the time was unclear; and that his death may have been caused or contributed to by errors in the identification and recording of the anniversary of his son’s death on his ACCT; his inappropriate transfer from F Wing; and an undue delay in responding to his cell bell on the evening of 21 March 2017. The medical cause of death was found to be: 1a post cardiac arrest hypoxic ischaemic brain injury; 1b ligature compression to the neck.
Circumstances of the Death
See section 3 above; Mr Doyle was found suspended by a ligature attached to the bars of his cell window on the evening of 21 March 207. Following emergency resuscitation he was taken to University College London Hospital, where he remained until his death on 28 March 2017 from injuries sustained by his suspension with the ligature.
Copies Sent To
Barnett, Enfield & Haringey Mental Health NHS Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.