Cherylin Norrell-Goldsmith

PFD Report Partially Responded Ref: 2014-0470
Date of Report 27 October 2014
Coroner Richard Travers
Coroner Area Surrey
Response Deadline est. 22 December 2014
Coroner's Concerns (AI summary)
Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not being readily available to prison staff on non-medical records. Data retention issues also exist.
View full coroner's concerns
During the course of the inquest the evidence revealed a number of  matters that gave rise to concerns that circumstances creating a risk of  other deaths will continue to exist in the future unless action is taken.  

1. Open pipe work with the cell  

Whilst it may not be possible to remove all potential ligature points  within a cell, removal of easily accessible and obvious ligature  points may serve to reduce the risk of self harm and suicide to  vulnerable prisoners. 

2. Multi‐Disciplinary Attendance / Input at ACCT Reviews 

Consideration should be given to ensuring that all staff, including  prison staff, healthcare staff and In Reach staff understand the  importance of requiring and providing multi‐disciplinary  attendance, or alternatively, multi‐disciplinary input at all ACCT  reviews.  

3. Retention of Primary Source Data within the Phoenix Programme  Consideration should be given to ensuring that all primary source  data (ie data provided by the prisoner to the therapist), should be  kept either in hard copy format or by way of faithfully recoding all  the detail contained therein on the prisoner’s System One record. 

4. Recording Significant Medical Events on a prisoner’s Non‐medical  Records  Consideration should be given to ensuring that all members of  healthcare and In Reach staff working within a prison  environment record all significant medical events that may impact  upon a prisoner’s risk assessment for self‐harm or suicide in a  Rt/doc/02536-2013/Reg28/27.10.2014

place or manner that is readily accessible to the discipline staff at  the prison, in addition to any entry made in respect thereof in the  System One record.
Responses
HM Prison and Probation Service Central Government
18 Dec 2014
Action Taken
The Ministry of Justice Estate Directorate is providing 'safer cells' in new construction and refurbishment projects. HMP Downview's local policies and procedures have been reviewed and strengthened, and the NHS England Area Team has produced data-sharing agreements. All staff will be reminded of ACCT procedures and the requirement to record significant information on both CNOMIS and SystmOne. (AI summary)
View full response
Dear being the cell" guide

relevant personnel must attend the reviews. Where a relevant member of staff cannot attend an ACCT review, then in exceptional circumstances_ and per the instructions of PSI64/2011, a written report will be submitted. When HMP Downview was a female prison, a system was in place to ensure that all staff who arrived for duty were provided with a list of prisoners subject to an ACCT and the date of the next ACCT case review in order that they could arrange to attend the review if they were involved in that prisoner's care_ This system will be reintroduced in Spring 2015. In addition, case managers will record in the ACCT document any significant personnel who are involved with the offender, including, health care , offender management and interventions or learning and development The case manager will also email relevant persons prior to the case review requesting their input to add to the details of the review and report: Prior to the re-opening of HMP_ Downview all prison staff, including personnel employed by partnership agencies within the prison will receive initial training or refresher training in the application of the ACCT procedures as part of their induction programme: The 2.5 hour training package will then be delivered by trained facilitators to each member of staff 2 years, and the programme of training will be monitored by the HR hub at the prison: (3) Retention of_primary_source_data_within_the Phoenix Programme Consideration_should be_given to ensuring_that_ alLprimary_source_data_should be_either_kept_in_hard_copY_format_Or_by_way_of faithfully recording all the detail contained on the_Prisoner's Systm One_ record The local policies and procedures at HMP Downview have been reviewed and strengthened where necessary_ The NHS England Area Team has produced data sharing Agreements which set out the required standard for sharing data between clinicians and also for a non-clinical (secondary) purpose NHS England is responsible for managing the audit and reporting for access to records in the clinical system (TPP SystmOne and its successor) and for the appropriate use of patient information: Providers are required to undertake spot checks of their own adherence to these Agreements either directly or through monitoring of the standards referred to above. resulting report on the findings of the audits concerning these Agreements can be reasonably requested by any Party to the agreement: (4) Recording significant medicalevents on a prisoner's non-medical records All staff, including health care staff;, will be reminded of the ACCT procedures and the requirement to record significant information about an individual's ~harm or suicide risks, on Cnomis (Custodial National Offender Management Information System) in addition to recording the information on SystmOne- (the electronic medical records system): The induction pack available for health care staff has also been updated to include governance information about ACCT procedures and what information can be shared with non healthcare professionals. hope this provides assurance that the specific issues identified in this case, both at the inquest and by the Prisons and Probation Ombudsman, are addressed.
Sent To
  • HMP Downview
  • Lord Chancellor
  • Surrey and Borders Partnership NHS Foundation Trust
  • Virgin Care
Response Status
Linked responses 1 of 4
56-Day Deadline 22 Dec 2014
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
The inquest into Mrs Norrell‐Goldsmith’s death was opened on the   2nd August 2013 and was resumed on 2nd October 2014 with a jury. It was  concluded on 27th October 2014.  The jury found that the cause of death was:       1a – Hanging.  They concluded with the following verdict:  Cherylin Angela Maria Norrell‐Goldsmith took her own life.
Circumstances of the Death
At shortly before midnight on the 26th July 2013 Mrs Norrell‐Goldsmith  was found in her cell at HMP Downview. She was partially suspended by  a ligature which had been attached to some exposed pipe work in the  Rt/doc/02536-2013/Reg28/27.10.2014

lavatory area within her cell. Assistance was summoned and CPR  commenced. Paramedics later attended but despite continued effort on  the part of those in attendance they were unable to revive her.  Mrs Norrell‐Goldsmith had been in custody since the 1st March 2012 and  had been on an ACCT for almost the whole of that time. In addition, she  had had long periods of counselling and, at the time of her death, was  receiving Dialectical Behavioural Therapy. She had been a prolific self‐ harmer whilst in prison and had been diagnosed as suffering from an  Adjustment Disorder. There was substantial documentation in relation to  her treatment and care.
Copies Sent To
I have sent a copy of this report to the following 1. The Lord Chancellor 3. The Chief Executive of Virgin Care 4. The Governor of HMP Downview SABP NHS Foundation Trust (Weightmans) (T.Sols) Virgin Care 6. The Chief Coroner  Signed Richard Travers Rt/doc/02536 2013/Reg28/27.10.2014 DATED this 27th October 2014                                    Rt/doc/02536 2013/Reg28/27.10.2014
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.