Dear Mr Butler Inquest into the death of Jack Portland Thank you for your Regulation 28 Report of 21 February 2017, addressed to the Governor of HMP Woodhill and the Chief Executive, Central and North West London NHS Foundation Trust (CNWL) , following the conclusion of the inquest into the death of Jack Portland on 27 December
2015. Your report has been passed to the Safer Custody and Public Protection Group in Her Majesty's Prison and Probation Service (HMPPS the agency that has replaced NOMS) , which is responsible for sharing learning from deaths in prison custody. reply on behalf of the Governor of HMP Woodhill: Your report raises four main concerns covering: ACCT management 2 Family involvement in the ACCT process and contact with the establishment 3 Discharge arrangements
4. Coordination of disclosure and witnesses statements. ACCT Management You will be aware from the evidence given at the inquest of the significant amount of activity that has taken place at HMP Woodhill to ensure that ACCT procedures are managed robustly and in line with Prison Service policy. Extensive training in suicide and self-harm prevention has been delivered to staff since Mr Portland's release from HMP Woodhill in 2015. During 2016 HMP Woodhill prioritised such training, and as a result over 93 per cent of managers at the prison have received Case Manager training, a significant improvement on previous years. In addition to the prioritisation of training delivery, new procedures have been introduced to ensure more robust management of the process_ During 2016 the Safer Prisons team introduced Case Manager Allocation and ACCT review booking systems, the aim of which is to ensure manageable caseload for Case Managers and to ensure consistent multi-disciplinary

attendance at ACCT reviews_ The team works extremely closely with the prison's healthcare providers, and CNWL were fully involved in the development of the new processes. Prison and healthcare staff work together to ensure attendance at the planned reviews_ In order to provide assurance that new procedures are fully embedded and effective , a review of the establishment's ACCT quality assurance processes took place in 2016. This led to the introduction of two new quality checks, one undertaken weekly by the wing manager and the other on a monthly basis by the Governor, which assess the quality and completeness of ACCT reviews and post-closure reviews. Both checks include section which requires managers to assess and comment specifically on the quality of caremaps and where deficiencies are found, feedback is given to the case manager andlor wing manager who are required to take the appropriate action to rectify this. After closure of an ACCT a post closure check will be completed by the Safer Prisons team: quality assurance template is used to check that the post closure process has been completed within timescales, that caremap actions were considered and completed prior to closure and that the prisoner has been invited to complete the closure questionnaire_ As with all quality assurance checks any feedback required will be provided to the Case Manager involved. The Governor is confident that the increased focus on the training of staff on the requirements of the ACCT process, and the robust quality checks now in place, have led to significant improvement in the quality, focus, and effectiveness of ACCT documents in supporting prisoners at risk of suicide and self-harm_ Family contact The value of family involvement for prisoners , and the significant resettlement opportunities that contact with family members presents are recognised: However the prison can only prompt this contact (and it could only be effective) with the consent of the prisoner During 2016 the prison has sought to further raise awareness of the value and importance of family contact and has seen significant improvement. Family members have been invited to and attended ACCT reviews; made telephone contributions and been involved in release planning for those prisoners on open ACCTs The Safer Prisons team is planning further work with Case Managers using some of the local examples with contributions from family members and prisoners_ During the review of the local Safer Prisons Policy in MaylJune 2017 the 'family pathway' will be developed to ensure active involvement of families wherever possible_ Discharge Since 1 June 2014 the provision of resettlement services for prisoners serving 12 months and under has been the responsibility of Community Rehabilitation Companies (CRCs) The prison works closely with the provider of resettlement services at HMP Woodhill; MTC Novo CRC, which is required to provide support services relating to housing and accommodation, employment training and education, finance benefit and debt. CRC staff meet all newly arrived prisoners to assess their immediate needs and necessary interventions. They then coordinate, deliver and signpost prisoners to interventions. Each prisoner will meet CRC staff 12 weeks prior to release and a review of resettlement plans will take place, with outstanding issues dealt with in an action plan: The prison actively supports the work undertaken by the CRC within the establishment: Since Mr Portland' s release from HMP Woodhill, the prison has introduced a new database system for the management of complex cases, which allows for the live sharing of information between the establishment; the CRC, Westminster Drug Project (the providers of substance misuse support) and CNWL The database allows a coordinated approach to resettlement planning, providing information relating to any concerns or issues and appointments upon Duty

release, for example with GPs, drug services and housing: This ensures that no referrals are being repeated and that everyone involved in the resettlement plan is fully aware of ongoing and required actions. The use of the database will be reviewed in July 2017 to ensure that it is fit for purpose and to consider how this information sharing is used to provide multi-disciplinary support to the most vulnerable and at risk individuals approaching release_ It has also been agreed at the multi-agency meetings that any immediate concerns regarding resettlement issues in complex cases will be shared with relevant departments by an immediate phone call, and recorded on the prisoner case notes. This is to identify and address safeguarding issues such as prisoners with accommodation issues and those suffering with mental health concerns From July 2017 , prisoners will be able to register with a GP practice before leave prison . The agreement includes the timely transfer of clinical information from the prison to the GP practice, with an emphasis on medication history and substance misuse management plans, to enable better care when a new patient first presents at the practice Prisoners will be actively supported to register with a GP Disclosure regret that the provision of documents to this inquest was not achieved in the way that we would wish, and would to apologise to you for the impact that this had on the inquest process: Much of this difficultly arose from the fact that; as Mr Portland died some months after his release from HMP Woodhill and when he was not in prison custody, the usual process by which prisons ensure that the paperwork required for disclosure to assist the Prison and Probation Ombudsman's investigation and the Coroner's Inquest is collated was not initiated. In consultation with GLD, we have agreed that in future all disclosure to the Coroner' s Court will be done through GLD to avoid confusion:. The late submission of written statements was the result f our desire to fully assist the inquest process by providing them from the most relevant members of staff. Due to a miscommunication we were not immediately aware that one member of staff would not be able to address all the issues raised. We have noted your concerns and will be addressing these in the longer term by increasing the resource in place to facilitate Coroner's inquests: Thank you for bringing these matters to our attention. trust that this letter has provided you with assurance that your concerns have been addressed.

Dear Mr Butler Regulation 28 Report to Prevent Further Deaths following the inquest concerning the death of Mr Jack Portland I am writing in response to the concerns raised in your Regulation 28 report dated 21 February 2017, which followed the inquest relating to Mr Portland’s death. Thank you for bringing these concerns to my attention. I will address your concerns in turn using your numbering. Concern 1 The provision of copies of leave forms is not in fact mandatory under either the Mental Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which suggests that this is the case, is misleading). Nevertheless, it is acknowledged that in many cases patients and their families find it useful to have a copy of the form in addition to being involved in discussions around the granting of any leave and conditions. The section 17 leave form has been amended and is currently going through the Trust’s governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017. The newly designed form allows the consultant to indicate, following discussions with patients and families, if copies should be provided and, if so, to whom. In addition, a new standard operating procedure (SOP) for managing leave (appendix 1) includes the need for staff to have a discussion with the family, where appropriate consent is given by the patient, regarding the patient’s leave from the ward and to do this every time there is a change to the leave agreed.

This SOP has been welcomed by Sapphire ward staff as it clarifies responsibilities and standards in relation to leave. After the testing period on Sapphire ward and a review, which is planned for end of April 2017, this SOP will be expanded and implemented across all adult wards. Concern 2 The new SOP referred to above is being tested on Sapphire ward. It clarifies and simplifies the management of leave on the ward. It gives clear instruction as to how leave is granted, the nursing level assessment, and simplifies the recording of leave on one collective ward document (appendix 2). The Trust acknowledges that the risk of human error when recording information in numerous places is unacceptable, and has therefore ended this practice. The team now works from one central document, and no longer records leave on a whiteboard. Concern 3(i) The new SOP includes the physical handover, once an hour, of the general observation chart between allocated staff. At handover both members of staff must now assure themselves that the sheet is fully filled in and in order. Staff have been strongly reminded that it is not appropriate to fill in observations paperwork prospectively or retrospectively. This is now monitored by the Matron. We are in the process of reviewing the Trust’s Observation Policy, and will ensure that this is also made very explicit within the new version. This policy review will be complete by the end of April 2017. Concern 3(ii) The responsibility for ensuring that patients are back from leave now clearly rests with the person allocated to carry out general observations. That staff member is also responsible for informing the shift co-ordinator, who will co-ordinate the implementation of the AWOL policy, if a patient does not return on time (appendix 3). The shift co-ordinator is always a qualified nurse. On occasions when a patient is AWOL the attached guidance clearly lays out the actions required and, in accordance with the AWOL Policy, staff should complete the Missing Patient Action Checklist to give a clear record of action taken. This has been clearly communicated to the team and added to every staff member’s supervision sheet to ensure that individuals have the opportunity to discuss the procedure and check their understanding. Copies of the attached guidance and Missing Patient Action Checklist are available on all acute inpatient wards for ease of reference and use. For all acute wards there is ongoing work using quality improvement methodology aimed at increasing the number of patients who return from leave on time. This work includes weekly

monitoring and review by the Matron of data collected on the wards showing the number of patients returning on time and late, which assists in identifying trends or issues. The team’s compliance with SOPs and any breaches are explored and relevant supervision and training implemented for individual staff when necessary. An existing SOP which covers shift co-ordination has had a new action added, which is that the shift co-ordinator signs off all relevant sheets, including observation charts, to ensure that all staff have fully completed the required paperwork, including the leave record form, and it is in order before handing over to the next shift. Concern 4 The admission checklist for the wards includes the requirement to update the risk assessment upon admission. This is further prompted by the electronic ‘patient status at a glance’ (PSAG) board in the nursing office. All qualified staff receive the Clinical Risk Assessment and Management training which includes consideration of the various sources of information a clinician may use to evaluate risk. In Mr Portland’s case, there was evidence of a handover from the Dene, however it is acknowledged that more effort should have been made in obtaining historic information from HMP Woodhill. This has been discussed with staff in the ward’s business meeting, and the Matron will continue to work with the team to ensure they meet the required standards of the Trust Clinical Risk Policy. This will be the responsibility of the Senior Matron who will ensure that historic risk information is obtained for those patients who have received care and treatment in a prison setting. Concern 5 An initial review is completed for every serious incident, as was the case following Mr Portland’s death. Each initial review report should be completed within 5 days of the incident/ death, reviewed by the senior clinical team and also by a weekly Trust wide executive meeting. The purpose of the initial review report is to set out the initial facts known, to identify any immediate action or learning required and to help develop the scope for the RCA investigation. The initial review report into Mr Portland’s death identified three immediate actions all around the timeliness of initiating the AWOL procedure. The initial review report was shared with the CQC. The first RCA investigation report was shared with the family, Coroner, commissioners and the CQC. We have acknowledged the mistakes in the timeliness and thoroughness of the first RCA investigation. In response to the concerns raised by the family, about the omissions in this first investigation report, identified at the first pre-inquest meeting, a third investigator did review the report. The initial plan was to add an addendum to the first RCA investigation report. However, this work highlighted weaknesses in the first investigation approach and identified further omissions, as well as learning around documentation. Therefore, following discussion with the CQC, commissioners and Buckinghamshire

Safeguarding Adult Review Group, the Director of Nursing made the decision to re-open the serious incident and to commission a new investigation with new authors. The timescale for completing the second RCA was 31 November 2016. This timescale was based on the national timescale of aiming to complete an investigation within 60 days. The family, commissioners and CQC were informed of this decision to commission a second RCA investigation and the timescale. The second RCA investigation was completed by two new investigators and a second internal review panel was convened (with different members from the first panel) by 31 November 2016. The report was then shared with the family, coroner, commissioner and CQC. We did not send a copy of the second final RCA investigation report to the family until 15 December 2016. We apologise, this was unacceptable and we do not have any satisfactory reason for this delay; it was as a result of an internal confusion about who was going to send the final report. The initial review report (completed within days of Mr Portland’s death) identified the immediate concerns and actions to be taken. The second RCA report therefore did not focus on the immediate actions taken, as this was not the purpose of this investigation. Concern 6 The Trust’s approach to the RCA process is that it is an open and supportive process with a focus on learning. Investigators do not routinely take formal statements or transcripts of meetings as part of the investigation; personal notes are kept to inform the investigation. Drafts of RCA reports are routinely shared with all staff interviewed and they are invited to feedback on content and accuracy at that stage. In this case, it was not felt that there was additional documentation available from the RCA investigations to further inform the Coroner’s investigation. The Trust does, and will continue to, cooperate in sharing information requested by Coroner, where such information or documentation is available. Concern 7 The second (final) RCA investigation report identified 4 recommendations based on the contributory factors to Mr Portland’s death, each with an action and timescale. It is acknowledged that there were additional concerns identified at inquest which included the understanding and implementation of the AWOL procedure, and the need to review how leave is managed, specifically around how information is recorded and the use of the whiteboard. The additional concerns will be added to the second RCA investigation report with appropriate corresponding actions, and the actions will be monitored centrally. In relation to concerns 5-7 (those specifically relating to the investigation of incidents), I can confirm that the following action has been taken:
- Communication and involvement of the family in the investigations did not meet the standard the Trust expects of staff. Therefore from March 2016 the patient safety manager became the family’s single point of contact to improve communication.

- A series of training sessions were held on promoting the status of families in investigations, ensuring they are central to the process (‘Making Families Count’), which were co-delivered with the charity Hundred Families in May and June 2016
- The Trust has improved its capacity for completing comprehensive and timely investigations, including appointment of a dedicated, full time post of RCA investigator/author in the adult mental health directorate. This person was appointed in February 2016.
- Weekly monitoring processes were introduced from July 2016 to better identify the right investigators, timely allocation of investigators and review of the progress of investigations. We now report on the timeliness of RCA investigations on a weekly basis to the Executive Team and quarterly to the Board of Directors.
- A survey completed of RCA investigators in August 2016 to ensure changes in training meets their needs.
- The Trust commissioned an external review of the quality of SI investigations completed in November 2016 to help the Trust to identify where and how to improve.

The following further actions are currently being or will be undertaken:
- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: . Timescale: new training to be delivered from 30th June 2017).
- The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: . Timescale: from 1st Nov 2017).
- New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: . Timescale: introduced from 1st July 2017).
- The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: . Timescale: 30th April 2017).

Once again, I thank you for bringing your concerns to my attention. I hope the information in this letter addresses your concerns and provides you with some reassurance that your concerns have been or are being addressed. If you require any clarification of further information, do not hesitate to get in touch.