Dear Mr Travers, Regulation 28 Report to Prevent Further Deaths following the Inquest of Mr Matthew Russell dated 27 November 2016 We write in response to your letter dated 2 December 2016 enclosing the Regulation 28 Report issued following the inquest into the death of Mr Matthew Russell: Central and North West London NHS Foundation Trust (CNWL) deeply regrets the death of Mr Russell and the distress this has undoubtedly caused his family: While Mr Russell did not die while in the care of CNWL, CNWL recognises the issues raised by the death of Mr Russell and the increasing number of deaths nationally. Our aim in responding to Regulation 28 and other deaths in custody nationally is to proactively contribute to multi-agency initiatives that reduce the likelihood of further deaths occurring: The matters of concern raised in the Regulation 28 report are set out below in bold followed by details of the action taken by CNWL and the actions we are proposing to take within the next 12 weeks_ CNWL were awarded the contract to provide Mental Health In-Reach services in HMP Highdown in 2015, one month after the death of Mr Russell: Since this time, we have continuously striven to improve the quality of services to patients, to increase the range of services available to patients with mental health problems. CNWL are consistently working with partners (who are separately contracted by commissioners) to deliver integrated care for patients with mental health problems The proper and regular monitoring of anti-depressant medication that is prescribed by way of a repeat prescription Approach to managing anti-depressant medication Many patients entering HMP Highdown will already be in receipt of anti-depressant medication. Nearly all this medication will have been prescribed by their GP or from Trust Headquarters, Stephenson House, 75 Hampstead Road, London NW1 2PL Telonhnne: 020 3214 5700 WWcnwLnhs uk Wellbeing for life CQTro4 Ett 2guGt FARTNERSHPP London Milton Keynes Kent Surrey Hampshire May

healthcare services in the transferring prison: The current primary care provider is Virgin Care until 31 March 2017, at which the primary care service will transfer to CNWL As of the current mobilization, CNWL will make contact with the community prescriber to both confirm the prescription and to clarify the treatment plan: Very frequently patients will have been in receipt of this medication for many years. In September 2016 CNWL undertook a review of patients on anti-depressants in HMP Highdown: The audit identified that on the 2hd September 2016 there were 229 patients on prescriptions for anti-depressants_ This represented nearly 23% of the prison population: The current national rate for anti-depressants in primarycare in the community is circa 8%. Mirtazapine was the most commonly prescribed anti- depressant: Mirtazapine has sedative properties and there was evidence from medical records that prisoners commencing on this drug often requested it by name There was evidence from the audit that many patients reported feeling depressed and anxious as a result of being in prison and reflecting on their current situation: This suggest that access to psychological therapies and support would enhance outcome rather than longer term pharmacological interventions and first line medications such as mirtazapine because of the sedative properties that can reinforce dependence The audit clearly identified the need to consider interventions that addressed insomnia, Which appeared to be & key factor in prescribing sedatinganti- depressants The review also questioned the efficacy of the PHQ9 (PHQ-9 is a multipurpose instrument for screening; diagnosing, monitoring and measuring the severity of depression) in the diagnosis of depression within the prison setting: Whilst CNWL recognises the principle of equivalence with community services where patients on anti-depressants are rarely referred to specialist mental health services, We aim to go beyond equivalence, recognising the complex needs of our patient group and the risks of imprisonment on mental health and wellbeing CNWLtis contracted and works within stepped model of care: We are currently auditing our services the new NICE guidelines for mental health services within prisons and the NICE guidelines for Anxiety and Depression This audit will be used tto identify gaps in provision and inform & review of the CNWL Mental Health pathway The CWYL Mental Health In-Reach Team provides a full range of services including: Consultation and support for the prison and other agencies in understanding and managing menta health problems. Integrated and interagency working in the treatment and management of Dual Diagnosis and multi-morbidity. Case management of patients referred to the mental health team Access to a range of therapies including CBT, psycho-education and groups for managing anxiety and depression. Managing repeat prescribing The prescriber is responsible for ensuring that a treatment plan is in place for the ongoing monitoring of repeat anti-depressant medication; In HMP Highdown we work in "conjunction with other prescribers with the clear understanding that the prescriber is responsible for ensuring the ongoing monitoring of compliance and point part would against

effectiveness of medication, including side effects (GPs and CNWL Psychiatrists/ NMP): This is supported through: In-line with community equivalence the GP would continue with repeat prescribing but would ensure the treatment plan assures them that the patient is in receipt of the appropriate level of supervision via primary care services. However; should the GP have any concerns around ongoing monitoring or psychological interventions, in-line with community equivalence, they are able to refer the patient to CNWL Mental Health services through the Single Point of Contact (SPOC) giving access to specialist assessment and access to range of psychological therapies. In-possession risk assessments to ensure patients can safely manage their own medication and that side effects are not a significant risk (includes risk of non-compliance and risk of diversion which is a significant risk in mood altering medication) Medication Use Reviews by Pharmacy staff (provided by Virgin Healthcare) _ Review by a Mental Health nurse if the patient is on their caseload_ Patients on the Mental Health caseload are reviewed through the weekly Case Review Meeting- Minutes of the case review meeting are provided to GPs and any risk or change in care and management plan recorded on SystmOne to ensure a full a multi-disciplinary approach to care Primary care nurses administer medication either daily or though in - possession medication and are able to monitor self-reported side effects by patients, poor compliance or concerns over patients not attending, which is recorded on SystmOne CNWL will liaise with Virgin Healthcare and Achor healthcare to ensure this is a standing agenda item on the Medicines Management group. AII CNWL Mental Health staff receive security training as part of their induction from the prison and as part of training: This includes reporting concerns over diversion of medication. Increased access to psychological therapies is a key strategy in the management and treatment of anxiety and depression. Ongoing use of anti- depressants can be addressed in patients care plan in Psycho-education groups and CBT therapies may touch on the use of medication in the treatment of anxiety and depression. However; these interventions enhance the required monitoring and do not replace them: A Standard Operating Procedure is in place to support GPs in the referral of patients to the service_ The Mental Health Team is currently finalising marketing material for staff and patients on the range of services available and referral criteria. prisoner who has had an antidepressant commenced by the CNWL psychiatrist will have had a comprehensive mental health assessment recorded on SystmOne In-line with community equivalence, it would be usual practice for the patient's key Any

prescribing to be referred back to Primary care; However; if the patient presents with complexity and high risk, the PsychiatristMH Non-Medical Prescriber will continue to prescribe. Any patient on the mental health caseload will have a case manager and will undergo further review by the Consultant Psychiatrist 1-2 weeks after prescribing is commenced. Once stabilised, the case management transfers from the Consultant Psychiatrist to the mental health nursing staff within the team who continue to monitor the patient and will refer back to the Consultant Psychiatrist if there are any issues, side effects or compliance concerns_ It is routine at all appointments/reviews that the nursing staff discuss both the current mental state and the ongoing use of medication including side effects, reduction and compliance with the patient: Where there are concerns identified _ these are then raised with the Consultant Psychiatrist and a further medical review arranged. The multi-agency Medicines Management group (led by Virgin healthcare) meets bi- monthly. Prescribing trends and issues concerning medication are standing items The CNWL Psychiatrist and GPs are routinely invited to the Multi-disciplinary meeting: Minutes of the meeting are circulated to all agencies. Any actions are recorded on SystmOne and via the task function on SystmOne; Any immediate concerns would be communicated directly to the GP by a member of the Mental Health team. CNWL have recently undertaken a full review of anti-depressant prescribing from SystmOne records. This included a review of the number of patients entering the prison on prescriptions. This review was undertaken by the lead Consultant Psychiatrist responsible for HMP Highdown: As a result of the review, a paper was provided to Commissioners and GPs, which will discussed via the commissioning process and the next Partnership Board; The review identified capacity issues within the Mental Health team due to the very high numbers of patients who are either historically prescribed in the community, or for whom prescribing commenced in either HMP Highdown or other prisons_ CNWL are currently reviewing our Standard Operating Procedure for working effectively with Primary care in managing dual diagnosis and co-morbidity via the Care Quality Management Meeting, and is due for review in February 2017 and ratification by the Clinical Director in April 2017.
b. The preparation of structured care plans for each patient All care is delivered in line with the service specification and CNWL mental health pathway and local process map and care pathway: In HMP Highdown; the Mental Health team leads the Multi-disciplinary meeting chaired by the Consultant Psychiatrist: GPs are invited to attend this meeting As a secondary mental health service, the focus is on patients with severe and enduring mental illness, and those with dual diagnosis and complex co-morbidity: As above, the minutes are circulated to GPs and outcome recorded on SystmOne, clearly identifying inter-agency management issues and risk: key element of the new CNWL model in the Surrey prisons is based on Medicines Optimisation for all patients, with pharmacy services focused on delivering individual

medication reviews that in turn informs individualised care planning: Our new Behavioural health model emphasizes building healthy behaviours that, where appropriate, reduce reliance on medications of dependence by a range of psychologically informed interventions that support pharmacological interventions. The Offender Care Psychosocial Strategy will be launched in March 2017. CNWL recognises that patients with depression who are traditionally managed in primary care are not fully reviewed in this meeting, as the secondary mental health care team does not have the capacity to do so, However;a full business plan is being developed by Prison GPs in consultation with CNWL Consultant Psychiatrist; to be submitted to NHSE to enable the team to take on the ongoing management of patients with anxiety and depression: A Care Plan audit was undertaken in October 2016. The audit identified that 100% of patients on the In-reach caseload had care plans in place_ The team is monitored on monthly basis on: 100% of urgent mental health referrals seen within 24 hours 100% of patients receive CPA review every 6 months HMP Highdown has been fully compliant with these CNWL key performance indicators (KPI) for the past 12 months_ This data is monitored at Directorate Divisional and Trust level: Local managers are required to provide exception reports on any breaches and to provide corrective action plans. However; as identified above, the majority of patients in receipt of anti-depressants be unlikely to meet these thresholds_ All staff in HMP Highdown underwent Best Practice Care Plan training in November
2016. C. An effective procedure for following up patients who fail to attend pre- booked appointments. The CNWL In-Reach Team has a DNA (Did Not Attend) Standard Operating Procedure in place which has been shared and discussed with all staff members_ CNWL is an experienced provider of healthcare in prisons and recognises there are a number of factors that may lead to a patient not attending an appointment: A member of the team will meet with patients who fail to attend any Mental Health Inreach appointment that day to establish the reason for non-attendance This now forms part of the daily function of the team: Where there are any concerns or risks identified; they will be seen by a member of the Inreach Team for a more detailed review that Where there are no immediate risks r concerns, a further appointment will be made and at that appointment the previous non-attendance will be discussed_ DNA rates are monitored and reported via the Contract monitoring process and the local team level: would day:

DNA rates are also discussed in the Partnership Board, themes identified, multi- agency responses identified and action planned. The Mental Health Inreach service has a Standard Operating Procedure in place for managing patients who DNA therapies appointments_ d_ The effective use of Read codes on System One record; to flag up and highlight significant risk factors in patient care: SystmOne is a national system used across all prisons_ Whilst it is a national system with national templates, it is possible for all agencies within the local healthcare system to customise and develop or alter specific areas of functionality: CNWL recognises that as a result of customization by the lead provider, staff locally, appear not to have been fully aware of how a partner agency was utilising the system on a daily basis_ CNWL recognises the need for improved interagency co-operation and communication in the local use of SystmOne: AII CNWL staff using SystmOne upon login are taken to the patienthomepage which includes an "exclamation mark icon" This icon identifies that a patient is of high risk of self-harm, open ACCTs, suicide risk and any other significant risk areas that staff need to be aware of: AII CNWL staff will receive refresher training by the end of February 2017 to ensure they know how to set this icon up on the client record should the need arise_ CNWL will raise this as an ongoing area of risk and opportunity in the multi-agency Partnership Board in February 2017 and ensure this is a standing agenda item. CNWL has a dedicated Performance Lead for the Surrey cluster and we will ensure a full review of the use of SystmOne is undertaken in each site; and that this is a standing agenda item in all local Clinical Quality Meetings We have recently appointed a performance and data analyst who is currently working with managers and senior clinicians across all our prison sites to improve local recording and support with local induction and ongoing support for teams_ CNWL is currently developing a training package for staff on the effective use of SystmOne on the functionality of the system, and the use of READ codes. We recognise that the homepage is a vital screen for agencies communicating risk and essential information in relation to a patient's care. All staff have been advised through local meetings of the requirement to log in via the homepage and this will be included in the CNWL Standard Operating Procedure going forward. CNWL has been appointed as the Lead provider for Primary Care Services in HMP Highdown and across the Surrey prisons cluster: As part of the mobilization and transfer process, CNWL will undertake a full review of the system in conjunction with partner agencies to optimise system usage and risk assessment and management processes across prescribing and pharmacy services This will include the development of a multi-agency protocol on the use of SystmOne that includes communication of risk and medicines optimisation.

CNWL is currently working closely with NHS England in preparation for the new version of SystmOne, which is due for rollout later in 2017. We are advised that all SystmOne templates have been reviewed to improve functionality across all prisons. It is our understanding that this new system will curtail the opportunity for agencies to make their own local changes The implementation of the new system will involve local training for staff. CNWL will implement a train the trainer programme to ensure ongoing support for staff post rollout
e. Ensuring all staff with responsibility for patients in prison have received adequate foundation training and on-going training in the ACCT procedure. ACCT training is prison provided training: CNWL works closely with the establishment to facilitate staff access training as far as possible within their probationary period. Following serious incidents in other establishments, CNWL established a Task and Finish Group in summer 2016. As a result of the lessons learned, the organisation has developed a number of initiatives that includes suicide prevention training: An e-Learning module for the management of harm and suicide in prison environments is a mandatory requirement for all staff joining CNWL on all prison sites. This training forms part of our mandatory training list and is retaken annually by all staff. At HMP Highdown, we are 100% compliant with this requirement: Statutory and mandatory training compliance is monitored via internal CNWL quality systems. Where non-compliance is identified, this would be addressed within a two week period. In addition to the CNWL Mandatory Suicide and Self Harm training, which includes ACCT processes, all new starters at HMP Highdown attend the prison ACCT training provided by the prison on local procedures and pathways this includes expectations of the team; the service and individual staff members' responsibility: Unfortunately, CNWL is dependent on the frequency of training within the prison. This has been raised directly with the Safer Custody Governor. We understand from recent discussions that safer custody are now looking to make this an annual refresher training course which all CNWL staff will attend. CNWL have developed a new e-learning package that details the ACCT process and outlines the specific roles and responsibilities of healthcare within this process. This will be rolled out within the next 3 months: The training will be mandatory for all CNWL staff working within secure settings. Compliance is monitored at a service and directorate level: Mandatory training and Continuous Professional Development is monitored via supervision_ Currently over 70% of CNWL mental health staff are ACCT compliant; the remaining three staff are currently non-compliant and 100% of staff have undertaken CNWL'$

Suicide and Self harm awareness training: We are working with the prison establishment to facilitate staff access to training as soon as possible. Delivery of ACCT training is the responsibility of the prison and has been raised at the Quality Partnership Board with the Safer Custody Lead Governor and we are awaiting dates from the prison for the full ACCT training: It should however be noted that all CNWL staff have completed CNWL's Suicide and Self Harm awareness training which includes basic ACCT refresher information. AIl CNWL staff who are not ACCT compliant do not take the lead in ACCT reviews and are supported by a CNWL staff member who has completed this full prison ACCT training: f_ Ensuring caseworkers are 2ware of and attend ACCT case reviews for patients under their care. Directorate Actions In summer 2016 CNWL, established a Task and Finish group that identified key themes in relation to Deaths in Custody: The group identified themes that included the ACCT process and healthcare's relationship, roles and responsibilities in relation to the ACCT. As a result; CNWL has developed a draft mental health pathway that includes both required standard operating procedure and also identifies gold standard that we would also seek to achieve. CNWL mental health pathway recognises the need for the Mental Health team to attend ACCT case reviews for all patients on the mental health caseload; Our pathway recognises as practice that the Mental Health team should attend all ACCT reviews. However; while this is accepted as a gold standard for prison mental health teams, CNWL is sometimes unable to meet this standard due to the capacity of mental health services_ Attendance is monitored via the monthly contract review meeting ittended by the prison, and capacity and local inter-agency operational issues are discussed and recorded. Following the recommendations of the Death in Custody Task and Finish Group; CNWL has now established the Clinical Oversight Group. The clinically led group reviews all serious incidents. It aims to reduce the likelihood of further incidents while examining in detail, emerging themes from serious incidents and near misses. The meeting is attended by the Trusts Lead for Serious Incidents ensuring lessons can be shared across Directorates and any Divisional and Trust learning can be effectively actioned: Directorate lessons learned are circulated via the Directorate Care Quality Meeting (CQM) and cascaded to all local CQMs for discussion and local implementation. Local Actions Local prison led operational procedures and communication is integral to the Mental Health team fulfilling this requirement CNWL are working actively with HMP Highdown to address these issues Safer custody at HMP Highdown now provide CNWL with Daily Open ACCT Log, which is sent to three managers within the team. This is then circulated to all staff on that day and daily copy posted on the Inreach Staff Office Notice Board. key good duty

During the daily morning briefing, which is attended by the CNWL mental health team, this log is reviewed to ensure that ACCT reviews are attended: Further; the duty RMN establishes, each morning, whether there have been any additions to the ACCT register and arranges to assess the prisoner that day: This has resulted in all prisoners who have an ACCT open being seen by a Mental Health Nurse within 24 hours of the ACCT being opened. This is a new initiative that has been in place since September 2016 Attendance at ACCT reviews is monitored quarterly, and where staff non-attendance is indicated, an exception report is included to outline the reasons for this absence Where there is an absence; for example; in case of late notification and availability or staff sickness, an ACCT contribution form regarding the mental state of the prisoner be provided to the ACCT Review by a member of the healthcare team: In an extreme situation where there is no staff availability, the mental health team will actively seek out feedback from the ACCT review.
g. Ensuring that there is regular communication about a patients needs with the GP and the primary healthcare practitioners at HMP Highdown. CNWL recognises the complexity of need, co-morbidity: and the prevalence of dual diagnosis in the patient population. We have implemented the following strategies: Appointment of a dedicated Regional Operations Manager to the Surrey_ cluster to lead and oversee the new CNWL Directorate integrated governance and quality assurance structures and processes including Lessons Learned from Serious Incidents, ensuring Board to Floor communication . Weekly Mental Health team meeting that includes standing open invitation to GPs. We do ensure that the agenda and minutes of the meeting are sent to the lead GPs_ Urgent matters that arise in this meeting are communicated in a timely way to the GP's if they are not present: Should the consultant psychiatrist not be present in the meeting then the responsible manager in that meeting contacts the Consultant Psychiatrist Other or non-urgent matters are discussed at the Complex Case Review meeting (see point below) Psychological Therapies supervision group led by CNWL Lead Psychologist providing feedback to referrers on areas of risk and concern via SystmOne Introduction of the CNWL Consultant Psychiatrist Complex Case Review Meetings at HMP Highdown to include GPs, Primary Care, Mental Health, Substance Misuse; Social Care, Safer Custody and Pharmacy that will commence in February 2017 to ensure that there is regular communication with all healthcare providers. CNWL Mental Health team is represented at all multi-agency integrated meetings including, but not limited to: Partnership Board, Quality Board Meetings, Medicines Management; Safer Custody, Drug Strategy meetings. will

In conclusion would Iike to state that CNWL regrets the death of Mr Russell and like to extend our sympathies to Mr Russell's family: As a significant provider of healthcare services within prisons we recognise the increasing risk to patient safety due to a number of complex and interrelated factors, some of which are outside the control of CNWL. However_ we would like to extend our assurances to yourself and the familythat we haveereviewed our governance structures and processes and our mental health pathway to ensure we are continuously learning lessons that enable us to positivel contribute to reducing the Iikelihood that anyone under our care dies in custody; We are actively working with NHSE and NOMs to address some of the national issues and docally we are working with NHSE commissioners to ensure that services are commissioned and resourced appropriately to meet the significant mental health care demand we are seeing in both HMP Highdown and prisons nationally: