Richard Green
PFD Report
Partially Responded
Ref: 2015-0456
Coroner's Concerns (AI summary)
Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack of clear display for critical historical information.
View full coroner's concerns
was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records_ These do not appear to have been recognised or_acted upon _by various medical professionals in the_prison system May May day May:
This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment: The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented As a result; there were missed opportunities which might have made a difference. Evidence showed that a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory). b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources It seems SystmOne was not easy t0 use, some staff unaware they could "search" and an absence of a way to clearly important historical information to ensure it was at the clinicians' finger tips_
This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment: The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented As a result; there were missed opportunities which might have made a difference. Evidence showed that a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory). b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources It seems SystmOne was not easy t0 use, some staff unaware they could "search" and an absence of a way to clearly important historical information to ensure it was at the clinicians' finger tips_
Responses
Action Planned
Greater Manchester West Mental Health Foundation Trust have commissioned a review of available assessment tools for the prison setting. NHS England are re-procuring the healthcare electronic healthcare system, SystmOne, which will include sharing of risk indicators. (AI summary)
Greater Manchester West Mental Health Foundation Trust have commissioned a review of available assessment tools for the prison setting. NHS England are re-procuring the healthcare electronic healthcare system, SystmOne, which will include sharing of risk indicators. (AI summary)
View full response
Dear Mr Roberts, Re: Death of Mr Richard Scott Green at HMP Haverigg on 9 May 2014 Thank you for your letter dated 2nd November 2015 regarding this sad case which was passed onto me by the Ministry of Justice. Nationally, it is recognised that identification of mental health problems, particularly depression and anxiety disorders, is poor within prisons1 due to the high incidence of co-morbities and dual mental health problems. It is also recognised that current evidence based tools, such as the PHQ9, are not reliable tools for assessing anxiety or depression within the prison population. NICE are currently developing guidelines on the identification and assessment of mental health of adults in contact with criminal justice system which includes prison. These guidelines will include identifying people at risk of developing and those with a mental health problem (including formal identification tools). A key concern for this guidance will be adapting existing NICE recommendations to the criminal justice system. The draft guidelines will be consulted on in June 2016 with an anticipated date for publication of November 2016. The current NHS England service specification, which healthcare providers are commissioned to deliver, states that all prisoners must undergo an initial health screen on receipt into establishment to identify any immediate health needs or risk, particularly in relation to suicide or self-harm. The Mental Health service specification requires all patients assessed by mental health services should use a suitable screening tool which adheres to national standards, such as National Service Framework for Mental Health (1999). 1 NICE DRAFT Guidelines on Mental Health of adults in contact with the criminal justice system. https //www.nrce.org . uk/guidance/indevelopment/gid-cgwave0726 Health and high quality care for all, now and for future generations
OFFICIAL-SENSITIVE PERSONAL HMP Haverigg mental health provider, Greater Manchester West Mental Health Foundation Trust have commissioned an in-trust review of all of the available assessment tools to ascertain if there is anything better placed for use in the prison setting. The review is expected to be completed by the end of January 2016. In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. 'increased risk of suicide') between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken. Cumbria Partnership Trust within HMP Haverigg are looking at the use of protocols to be used on SystmOne to pick up some key words within patient records, such as intoxication, intoxicated, illicit, spice, NPS, psychosis, self-harm, suicide that will be highlighted on the system and flag that there is a risk. The work is being carried out in consultation with other providers in the prison and in collaboration with NECs with the intention of putting protocols in place as soon as practicable.
OFFICIAL-SENSITIVE PERSONAL HMP Haverigg mental health provider, Greater Manchester West Mental Health Foundation Trust have commissioned an in-trust review of all of the available assessment tools to ascertain if there is anything better placed for use in the prison setting. The review is expected to be completed by the end of January 2016. In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. 'increased risk of suicide') between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken. Cumbria Partnership Trust within HMP Haverigg are looking at the use of protocols to be used on SystmOne to pick up some key words within patient records, such as intoxication, intoxicated, illicit, spice, NPS, psychosis, self-harm, suicide that will be highlighted on the system and flag that there is a risk. The work is being carried out in consultation with other providers in the prison and in collaboration with NECs with the intention of putting protocols in place as soon as practicable.
Sent To
- Ministry of Justice
- National Offender Management Service
Response Status
Linked responses
1 of 2
56-Day Deadline
28 Dec 2015
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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 14"h 2014 an investigation was commenced into the death of Richard Scott Green; aged 23 years The investigation concluded at the end of the inquest on 23rd October 2015. The conclusion of the inquest was (a) Death by Hanging Open Conclusion
Circumstances of the Death
The deceased was found hanged in his cell at Haverigg Prison on g"h 2014 He had made a ligature from a torn bed sheet and had used the narrow gap at the top of the door leading to his en-suite shower room as a ligature point: The Jury found that bullying and debt had contributed to his death. Whilst satisfied he had placed the noose about his neck, the Jury were not satisfied so as t0 be sure that he intended to kill himself. Evidence also showed he had, apparently unjustly, been refused a family visit on 27th He had a well documented history of self-harm and apparent suicide attempts
Action Should Be Taken
Minister of Justice and Head of Prison Service_ Action to be taken to consider the development of:
1) A tool or process to help clinical staff better assess and predict those prison inmates who are at greatest risk of deliberate self-harm or suicide
2) Improvements to the SystmOne clinical records to make them more fit for purpose so that important entries relating to deliberate self-harm or suicide are easily accessible and staff have requisite training sO can use the system efficiently and to best advantage
1) A tool or process to help clinical staff better assess and predict those prison inmates who are at greatest risk of deliberate self-harm or suicide
2) Improvements to the SystmOne clinical records to make them more fit for purpose so that important entries relating to deliberate self-harm or suicide are easily accessible and staff have requisite training sO can use the system efficiently and to best advantage
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.