Andrew Hall
PFD Report
Partially Responded
Ref: 2014-0122
Coroner's Concerns (AI summary)
Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
View full coroner's concerns
the course of the inquest the evidence revealed matters giving rise to concem; In opinion there is & risk that future deaths will occur unless action is takeng n &he crconcsances iT1Y it is my statutory to report to you. The MATTERS QE CONCERN are set out below I have for ease of reference highlighted in bold type where a particular body or organisation is specifically referred and in brackets at the end of the entry, where the jury were silent but where I consider the body or organisation referred to has responsibility to deal with it _ In the assessment of risk and risk management the found (inter alia) information provided by mental healthcare nursing staff to Prison Officers was not correctly documented. There was inadequate communication between members of the Mental Health as to the deceased's condition and the level ofrisk of self-harm_ S:IAGE PERSONALIAGE InquestslHall Inquest Reg28 docx Tees; Valley the During duty tO, being jury team
There was inadequate communication between members of the Mental Health Team and the Healthcare Unit staff as to the deceased' s perceived condition and level of risk of self-harm There was inadequate communication between the Mental Health In Reach Team and the mental care unit staff as to the type and level of observation required when the deceased was re-admitted to the Healthcare Unit on 23 March 2009. Insufficient attention was paid by healthcare professionals to the system entries That both mental health staff and general staff inadequately took into account the entry made by That & post-closure interview in accordance with the (then) ACCT policy should have been conducted. Prison staff; healthcare staff and Mental Health team Medication was not administered to the deceased on 23 March 2009 and 24 March 2009 as prescribed: Medical healthcare staff) The deceased was not adequately observed between 6.3Opm and 7.3Opm on 27 March 2009 . (Healthcare stafffPrison discipline officers)
10. The quality of CCTV images within the healthcare unit Was inadequate. prison service)
11. Arrangements for staff members to use the CCTV screens were absent: (Prison service & Healthcare staff) 12.0 There was infrequent observation of the CCTV screens on March 2009. (Prison service & Healthcare staff)
13. Generally the training and induction to visiting Psychiatrists in respect of the ACCT process was relevant to the circumstances in which the deceased died
14. The practice of healthcare professionals regarding the of previous entries was also relevant to the circumstances in which the deceased died, system 15 . The awareness of prison policies in relation to the use of camera cells was also relevant to the circumstances in which the deceased died (Prison service & Healthcare staff)
16. The training and instructions given to prison officers and staff regarding use of and manipulation of the CCTV image was also "relevant" to the circumstances in which the deceased died
There was inadequate communication between members of the Mental Health Team and the Healthcare Unit staff as to the deceased' s perceived condition and level of risk of self-harm There was inadequate communication between the Mental Health In Reach Team and the mental care unit staff as to the type and level of observation required when the deceased was re-admitted to the Healthcare Unit on 23 March 2009. Insufficient attention was paid by healthcare professionals to the system entries That both mental health staff and general staff inadequately took into account the entry made by That & post-closure interview in accordance with the (then) ACCT policy should have been conducted. Prison staff; healthcare staff and Mental Health team Medication was not administered to the deceased on 23 March 2009 and 24 March 2009 as prescribed: Medical healthcare staff) The deceased was not adequately observed between 6.3Opm and 7.3Opm on 27 March 2009 . (Healthcare stafffPrison discipline officers)
10. The quality of CCTV images within the healthcare unit Was inadequate. prison service)
11. Arrangements for staff members to use the CCTV screens were absent: (Prison service & Healthcare staff) 12.0 There was infrequent observation of the CCTV screens on March 2009. (Prison service & Healthcare staff)
13. Generally the training and induction to visiting Psychiatrists in respect of the ACCT process was relevant to the circumstances in which the deceased died
14. The practice of healthcare professionals regarding the of previous entries was also relevant to the circumstances in which the deceased died, system 15 . The awareness of prison policies in relation to the use of camera cells was also relevant to the circumstances in which the deceased died (Prison service & Healthcare staff)
16. The training and instructions given to prison officers and staff regarding use of and manipulation of the CCTV image was also "relevant" to the circumstances in which the deceased died
Responses
Action Taken
Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is now in place to ensure post-closure reviews of ACCTs take place within seven days, and a local policy for an additional review after one month has been introduced. (AI summary)
Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is now in place to ensure post-closure reviews of ACCTs take place within seven days, and a local policy for an additional review after one month has been introduced. (AI summary)
View full response
Dear Mr Eastwood INQUEST INTO THE DEATH OF MR ANDREW HALL AT HMP HOLME HOUSE ON 27 MARCH 2009 Thank you for your Regulation 28 report dated 12 March 2014,which has been passed to Equality, Rights and Decency Group in the National Offender Management Service (NOMS) , as we have policy responsibility for suicide prevention and self- harm management; and for sharing learning from deaths in custody. am responding on behalf of NOMS and HMP Holme House, and will address each of the points that you have made that refer to prison staff or the prison service_ You are concerned that information about risk provided by mental healthcare nursing staff to prison staff was not correctly documented (point 1). ACCT reviews are chaired by supervising officers who record any information about risk that is received from the mental health team: Where a prisoner has mental health issues, a member of the mental health team is invited to attend all ACCT reviews_ The mental health team has received ACCT training, and further training sessions are arranged when new members join the team_ Mental health staff play an active role in the management of ACCT plans, and a significant number of ACCTs are opened by the team: The prison's regular management checks confirm that members of the mental health team attend reviews and that their contributions are recorded. You are concerned that a post-closure review of the ACCT was not conducted (point
7). A system is now in place within the safer custody department to ensure that all post-closure reviews take place within the seven day period mandated in Prison Service Instruction (PSI) 64/2011 Safer Custody. A local policy that an additional post-closure review is conducted after one month has been introduced. You raise a number of concerns about the effectiveness of the arrangements to observe prisoners in cells in the healthcare centre using CCTV (points 9-12, 15 and
16). Cameras have been removed from all cells and any prisoner assessed as requiring high levels of observation is located in a constant observation cell and subject to constant supervision in accordance with the arrangements set out in chapter 6 of PSI 64/2011 . You are concerned about the adequacy of the induction and training on the ACCT process provided to visiting psychiatrists (point 13). All new staff who work with prisoners are provided with an induction that includes guidance on the ACCT process. Training on ACCT has been provided to all visiting psychiatrists, and further courses will be arranged as required_ Petty
hope this provides you with assurance that the points that you have raised for prison staff andlor the prison service have been fully addressed:
7). A system is now in place within the safer custody department to ensure that all post-closure reviews take place within the seven day period mandated in Prison Service Instruction (PSI) 64/2011 Safer Custody. A local policy that an additional post-closure review is conducted after one month has been introduced. You raise a number of concerns about the effectiveness of the arrangements to observe prisoners in cells in the healthcare centre using CCTV (points 9-12, 15 and
16). Cameras have been removed from all cells and any prisoner assessed as requiring high levels of observation is located in a constant observation cell and subject to constant supervision in accordance with the arrangements set out in chapter 6 of PSI 64/2011 . You are concerned about the adequacy of the induction and training on the ACCT process provided to visiting psychiatrists (point 13). All new staff who work with prisoners are provided with an induction that includes guidance on the ACCT process. Training on ACCT has been provided to all visiting psychiatrists, and further courses will be arranged as required_ Petty
hope this provides you with assurance that the points that you have raised for prison staff andlor the prison service have been fully addressed:
Sent To
- National Offender Management Service
- North Tees and Hartlepool NHS Trust
- Tees, Esk and Wear Valleys NHS Foundation Trust
Response Status
Linked responses
1 of 3
56-Day Deadline
7 May 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
Circumstances of the Death
Between 19.20 hours and 19.35 hours On 27 March 2009 in cell 5 of Health Care Unit at HM Holme House Prison the deceased caused incised wounds to his neck causing hypovolacmicashock which caused his death: On the said date the deceased was an inmate detained lawfully at Her Majesty Prison Holme House_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and /or organisation the power to take such action. your
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.