Ian Brown
PFD Report
Partially Responded
Ref: 2016-0200
Coroner's Concerns (AI summary)
Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued rises in suicide and self-harm due to inadequate ACCT case management.
View full coroner's concerns
_ (1)During the course of the evidence was referred to the most recent report from the HM Inspector of Prisons that highlighted 'Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self har , had not been implemented with sufficient rigour.
(2) Deaths at the prison from suicide and self harm continue to rise_ (3) The recommendation from the Inspectors is that there should be a "prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It_should also include Gary improvements in the quality of ACCT case management documentation , and the lessons learned from internal investigations into life-threatening incidents_ have concerns that the recommendations will not be implemented and that past recommendations have been ignored.
(4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise .
(2) Deaths at the prison from suicide and self harm continue to rise_ (3) The recommendation from the Inspectors is that there should be a "prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It_should also include Gary improvements in the quality of ACCT case management documentation , and the lessons learned from internal investigations into life-threatening incidents_ have concerns that the recommendations will not be implemented and that past recommendations have been ignored.
(4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise .
Responses
Action Taken
NOMS has introduced a monthly forum to monitor progress on actions taken in response to recommendations relating to recent deaths in custody, delivered case management training to 90% of managers who chair ACCT case reviews, and is implementing a system to provide each offender supported through the ACCT process with a designated case manager. (AI summary)
NOMS has introduced a monthly forum to monitor progress on actions taken in response to recommendations relating to recent deaths in custody, delivered case management training to 90% of managers who chair ACCT case reviews, and is implementing a system to provide each offender supported through the ACCT process with a designated case manager. (AI summary)
View full response
Dear Mr Osborne
Thank you for your Regulation 28 report dated 26 May 2016 addressed to
Governor of HMP Woodhill, and , the former Prisons Minister, concerning the recent inquest into the death of Ian Brown on 27 February 2015. Your report has been passed to the Equality, Rights and Decency (ERD) Group at NOMS headquarters, as we have responsibility for the policy on suicide prevention and self-harm management and for sharing learning from deaths in custody. I have consulted with the Governor of HMP Woodhill in formulating this response.
You have raised concern in your report that you lack confidence that HMP Woodhill will implement recommendations from Her Majesty’s Inspectorate of Prisons (HMIP) and the Prisons and Probation Ombudsman (PPO), and address the matters of concern that you have raised in previous cases. Please be assured that the Governor absolutely understands your concern and is committed to making the improvements to be realised from implementation of these recommendations.
Following the recent inspection by HMIP, a monthly forum, chaired by the Deputy Governor, has been introduced to monitor progress on the actions being taken in response to all recommendations relating to the recent deaths in custody. This forum will improve assurance of compliance. A whole establishment action plan, shared by the health provider and the prison, is in place and progress on this is formally monitored monthly and reported to both the prison Senior Management Team meeting and the newly established Clinical Governance meeting.
As I explained in my letter of 6 February 2016 in response to a previous Regulation 28 report, the Deputy Director of Custody for High Security Prisons established a taskforce to conduct a review of safer custody processes at the prison, and this group now meets quarterly, chaired by the Deputy Director, to oversee the implementation of the action plan to address the recommendations of the review. Through the taskforce extra resources have been provided to the prison to assist in data analysis, focus groups and other research. At the same time the healthcare provider, Central North West London NHS Foundation Trust, completed a review of healthcare services at the prison.
An early example of the improvement that is being driven by the taskforce is in the management of the ACCT process. The establishment has now delivered Case Management
training to 90% of managers who chair ACCT case reviews. A new case review booking system is in place to improve the continuity of case manager attendance and to ensure that all members of the multi-disciplinary team are able to plan their attendance at review meetings. The prison is also implementing a system to provide each offender supported through the ACCT process with a designated case manager throughout the period for which the ACCT remains open. This approach will bring further improvement in the quality and consistency of case reviews and care plans.
The planned improvements to safety at the prison go much wider than the ACCT process, including: an ‘every contact matters’ approach to the way that staff engage with prisoners; a streamlined early days in custody process, from the point of reception until the end of induction, managed by the residential team; and measures to increase the involvement of prisoners in decision-making, including the introduction of ‘citizenship’ groups to provide support to at-risk prisoners.
I hope this provides you with assurance that the Governor of HMP Woodhill, and the Deputy Director of Custody for High Security Prisons, have put in place processes and governance that will achieve successful action in response to the recommendations from HMIP and the PPO, and the matters of concern raised in your Regulation 28 reports, and that this will bring the necessary improvements in safety at the prison.
Thank you for your Regulation 28 report dated 26 May 2016 addressed to
Governor of HMP Woodhill, and , the former Prisons Minister, concerning the recent inquest into the death of Ian Brown on 27 February 2015. Your report has been passed to the Equality, Rights and Decency (ERD) Group at NOMS headquarters, as we have responsibility for the policy on suicide prevention and self-harm management and for sharing learning from deaths in custody. I have consulted with the Governor of HMP Woodhill in formulating this response.
You have raised concern in your report that you lack confidence that HMP Woodhill will implement recommendations from Her Majesty’s Inspectorate of Prisons (HMIP) and the Prisons and Probation Ombudsman (PPO), and address the matters of concern that you have raised in previous cases. Please be assured that the Governor absolutely understands your concern and is committed to making the improvements to be realised from implementation of these recommendations.
Following the recent inspection by HMIP, a monthly forum, chaired by the Deputy Governor, has been introduced to monitor progress on the actions being taken in response to all recommendations relating to the recent deaths in custody. This forum will improve assurance of compliance. A whole establishment action plan, shared by the health provider and the prison, is in place and progress on this is formally monitored monthly and reported to both the prison Senior Management Team meeting and the newly established Clinical Governance meeting.
As I explained in my letter of 6 February 2016 in response to a previous Regulation 28 report, the Deputy Director of Custody for High Security Prisons established a taskforce to conduct a review of safer custody processes at the prison, and this group now meets quarterly, chaired by the Deputy Director, to oversee the implementation of the action plan to address the recommendations of the review. Through the taskforce extra resources have been provided to the prison to assist in data analysis, focus groups and other research. At the same time the healthcare provider, Central North West London NHS Foundation Trust, completed a review of healthcare services at the prison.
An early example of the improvement that is being driven by the taskforce is in the management of the ACCT process. The establishment has now delivered Case Management
training to 90% of managers who chair ACCT case reviews. A new case review booking system is in place to improve the continuity of case manager attendance and to ensure that all members of the multi-disciplinary team are able to plan their attendance at review meetings. The prison is also implementing a system to provide each offender supported through the ACCT process with a designated case manager throughout the period for which the ACCT remains open. This approach will bring further improvement in the quality and consistency of case reviews and care plans.
The planned improvements to safety at the prison go much wider than the ACCT process, including: an ‘every contact matters’ approach to the way that staff engage with prisoners; a streamlined early days in custody process, from the point of reception until the end of induction, managed by the residential team; and measures to increase the involvement of prisoners in decision-making, including the introduction of ‘citizenship’ groups to provide support to at-risk prisoners.
I hope this provides you with assurance that the Governor of HMP Woodhill, and the Deputy Director of Custody for High Security Prisons, have put in place processes and governance that will achieve successful action in response to the recommendations from HMIP and the PPO, and the matters of concern raised in your Regulation 28 reports, and that this will bring the necessary improvements in safety at the prison.
Sent To
- HMP Woodhill
- Minister for Prisons
Response Status
Linked responses
1 of 2
56-Day Deadline
22 Jul 2016
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 20/07/2015 commenced an investigation into the death of Ian Keith Brown, 44 The investigation concluded at the end of the inquest on 26 April 2016. The conclusion of the inquest was set out in the Jury's narrative conclusion set out in their answers to the questionnaire_
Circumstances of the Death
Mr Brown suffered from mental illness and had been on remand at HMP Woodhill since the 1Oth January 2015 and occupied Cell 301 in House Block 3B.At 12:10 hours on Sunday the 19th July 2015 he was locked in his cell (he was the only occupant) , he pressed his bell: PO Lindop responded and Mr Brown said he wanted to speak to Senior Officer Miss Jones_ He was told that she was on her lunch break and could probably come and see him after her break At 13.10 hours 19/07/2015 PO Phil Arthur started his rounds to check the cells_ Mr Brown's cell was the first one. The PO looked through the hatch and saw that Mr Brown was slumped forward in his chair facing the window. There was a belt ligature tied around his neck which was connected to the window: PO Arthur called a "code blue" (prisoner not breathing) through his radio for help. He then entered the cell and cut the ligature with his fish knife and proceeded to do CPR until Healthcare arrived. An ambulance was called and Paramedics confimed death at 14.00 hours_ A short note written t0 his sister was found in his cell.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.