NHS England Commissioners The evidence established a significant unmet need for psychological therapies to treat patient prisoner suffering from personality disorders or those suffering from traits of such personality disorders. These prisoners are recognised as being at higher risk of self harm which may ultimately result in death or suicide. Without NHS Commissioners allocating more resources to identifying and treating such patients there is a concern that further prisoners suffering_trom him The very these conditions will end up deliberately or accidentally killing themselves MHSC and HMPS locally at HMP Manchester am concerned that the appropriate sharing of information relating to risk and suicidal or self harming behaviour did not take place between the clinical team and HMPS staff. For example, the direct threat of suicide made at the review on the 27 November 2012 was not disclosed to HMPS staff . Appropriate , timely mutual information exchange had not taken place and there is a concern that this may be vital but may be overlooked if steps are not taken to make this a matter of routine. It means that clinical staff have to be able to review the clinical record appropriately and share information with their HMPS colleagues. am concerned at the lack of attendance of the Consultant Psychiatrist or a suitably qualified and experienced junior colleague at the discharge case reviewlmeeting: In a case of patient still on an ACCT and being discharged to an ordinary location without as senior clinician able to attend and participate in the discharge case review risk assessment at that stage and risk planning: In this case there was no attendance on the 6 December 2012 and no clinician had seen him since 27 November 2012 This would allow a more sophisticated and timely assessment of risk at that time. Measures to try and reduce or mitigate the risks could then be discussed and put in place in a graduated manner. It is appreciated that such case reviews may have to be rearranged so as to facilitate full attendance: The court has previously identified the concern arising from that fact that no senior clinician took the opportunity at the appropriate time to stand back and take an overall view of the entire circumstances and the risks presented. am concerned by the lack of planning or consideration of a graduated risk management plan in such circumstances_ This was identified by the clinical reviewer In other words increased frequency of time interactions and throughout the whole day and MHIT and Psychiatrist contacts shortly after the move. In this case the deceased was on the waiting list for a MHIT contact and was due to be seen within 2 weeks by the Psychiatrist. HMPS locally at HMP Manchester and HMPS nationally At the present time the HCC caters for some 22 patient prisoners and has 10 safer cells. am concerned that the prison has a very limited number of safer cells on a limited number of other wings. At the present time there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures ). If prisoners are subject to ACCT's and either transferred from one wing to another or transferred from the HCC to an ordinary wing location for what ever reason there is no half way house facility providing increased levels of safety_ The provision of safer cells has demonstrably reduced the opportunity for fatal self harming in the over whelming majority of cases Without HMPS investing in the provision of safer cells on every or an increased number of wings there is a concern that prisoners will continue to kill themselves in non safer cells when are on ACCT's. The same considerations would apply nationally to the entire HMPS estate. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures_ No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell's death: One reason given was that if were_used it required a Prison Ofticer wing being day very wing they Very they to be monitoring the CCTV images constantly 24 hours a day: could of course be used as an adjunct or in addition t0 usual ACCT observation procedures. This would not require constant CCTV monitoring: NOMS have replied to the court's Regulation 28 PFD report and a copy is attached: am concerned that if such cellslfacilities are not provided and used then there is a risk that prisoners on ACCT's will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner's guidance in relation to Mr Gillard's death.