Cherylin Norrell-Goldsmith
PFD Report
Partially Responded
Ref: 2014-0470
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.
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
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)
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.
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
- 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.
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
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Improve perinatal mortality recording
Morecambe Bay Investigation
Inaccurate and inaccessible patient records
Detainee Capture and Condition Records
Al-Sweady Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.