Adrian Johnson
PFD Report
Partially Responded
Ref: 2013-0364
Coroner's Concerns (AI summary)
The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack of consistency in case management, with no handover from case manager to case manager.
View full coroner's concerns
During the course of the inquest the evidence revealed matters giving rise to concern in each of these areas: Circumstances related to initial screenings in the First Night Centre: a) The nurse conducting the primary reception screen said that she could not ask questions about smoking or withdrawal as she was not toxicology trained. b) The doctor to whom Mr Johnson was referred in the First Night Centre by the nurse, said that she did not routinely assess smoking habits and that she expects the matter to be covered by nurses. She does not get involved in tobacco issues_ c) The nurse who conducted the secondary screen recorded the number of cigarettes that she said he smoked; but did not ask any questions about withdrawal, The mental health nurse who later saw Mr Johnson, on referral by the doctor said that smoking was not his area; he assumed it was assessed in reception.
0) There was no health care worker who assessed whether he had problems with wilhdrawal from tobacco. According to the exert witness, Drb who was a GP with substantial experience working in prisons, for this patient, withdrawal and agitation due to lack of tobacco was obviously an issue_ He said that nicotine withdrawal was very important in this case, increasing the patients vulnerability and anxiety and thus his risk Dr said that this prisoner had made it very clear that; although a majority of prisoners can manage their tobacco withdrawal, he could not; so that vigilance should have been higher and greater steps taken to support this, which becomes highly relevant when we see him moving to health care, which is a smoke free environment: He said that he would have treated him with a patch or lozenges to reduce anxiety, or he might use Diazepam_ There was a prescription of Diazepam, but it was not in the dose given in the previous prison and police station on transfer, it was not administered when the prescriber intended and was not prescribed for tobacco withdrawal: g) Dr who was Chair of the RCGP Secure Environments Group, advised that tobacco use should be screened for a8 part of the reception screen in the first 24 hours, including a question as to whether tobacco withdrawal might be a problem He was sufficiently concerned that without such a question in routine use in prisons, there was a potential risk to future lives and recommended that | should make a prevention of deaths report, to those named: Circumstances related to ACCT Reviews a) The ACCT review on 11/05/2010 chaired by Officer A, was held without input from health care, despite the main trigger for his self suspension days earlier being anxiety related to tobacco withdrawal: b) The court heard that a governor did not know that the prisoner was on an open ACCT when he was informed of his initial transfer to the segregalion unit being c) There was a lack of consistency in case management; with no handover from case manager Officer A (who was not informed or invited to the subsequent reviews) to the case manager of the ACCT review on 12/05 or to the ACCT review with a third case manager, chaired by the governor on 13/05. This appeared not be in compliance with PSO guidance_ The attendees for enhanced care team review on 13/05 were not selected by the governor, who was in the chair, who left the invitations to the Segregation Unit_ A psychologist was not invited, contrary to local guidance. Health care was invited at the last minute with no notice to prepare.
0) The health care member attended with very little knowledge of the case. He did not know that there was an alcohol abuse history and did not discuss his personality disorder, possible prior diagnosis of schizophrenia or potential withdrawal problems _ He did not know of the Diazepam prescribing prior to admission or at Belmarsh. It was not clear that the review team had been informed of an admission by the prisoner that the recent ligalure was & serious attempt on his life_ A LISA form was completed at reception, giving details of Diazepam dependency; alcohol abuse, past history of schizophrenia, previous in patient psychiatric care and current antidepressants but this information was not available to the Review teams The listed Caremap areas for consideration were not all considered. Action to link the person to people who can provide support did not include his family (after the two minute reception call): Actions to encourage alternatives to self injury, to reduce emotional pain caused by practical problems, action to reduce vulnerability because of mental health problems and action to reduce vulnerability because of drug and alcohol problems were either not or inadequately considered. The governor agreed that he had not conducted a comprehensive careplan: g) Many of those actions required mental health assessment, which was not conducted before he died, which the expert said should have been done in 48hrs of admission, and not it was a really serious failure_ The last ACCT review did not consider whether or when it would be done. h) The last Review agreed the reduction of observations to hourly, without any information from mental health assessment: The governor had not seen the entry in the prison records that Mr Johnson was at high risk of impulsive behaviour causing accidental suicide. Had he known that; he would have asked for the results of the mental health assessment prior to downgrading his observations The expert was critical of Ihe decision to him in Segregation Unit; in the light of his vulnerability and health problems. It was not clear that all other options had been fully explored: this was not an item considered at the last ACCT Review: doing keep
_ (1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks t0 the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit; nor in the way in which members were asked to attend, nor the adequacy of caremap planning: The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manger and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit: Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
0) There was no health care worker who assessed whether he had problems with wilhdrawal from tobacco. According to the exert witness, Drb who was a GP with substantial experience working in prisons, for this patient, withdrawal and agitation due to lack of tobacco was obviously an issue_ He said that nicotine withdrawal was very important in this case, increasing the patients vulnerability and anxiety and thus his risk Dr said that this prisoner had made it very clear that; although a majority of prisoners can manage their tobacco withdrawal, he could not; so that vigilance should have been higher and greater steps taken to support this, which becomes highly relevant when we see him moving to health care, which is a smoke free environment: He said that he would have treated him with a patch or lozenges to reduce anxiety, or he might use Diazepam_ There was a prescription of Diazepam, but it was not in the dose given in the previous prison and police station on transfer, it was not administered when the prescriber intended and was not prescribed for tobacco withdrawal: g) Dr who was Chair of the RCGP Secure Environments Group, advised that tobacco use should be screened for a8 part of the reception screen in the first 24 hours, including a question as to whether tobacco withdrawal might be a problem He was sufficiently concerned that without such a question in routine use in prisons, there was a potential risk to future lives and recommended that | should make a prevention of deaths report, to those named: Circumstances related to ACCT Reviews a) The ACCT review on 11/05/2010 chaired by Officer A, was held without input from health care, despite the main trigger for his self suspension days earlier being anxiety related to tobacco withdrawal: b) The court heard that a governor did not know that the prisoner was on an open ACCT when he was informed of his initial transfer to the segregalion unit being c) There was a lack of consistency in case management; with no handover from case manager Officer A (who was not informed or invited to the subsequent reviews) to the case manager of the ACCT review on 12/05 or to the ACCT review with a third case manager, chaired by the governor on 13/05. This appeared not be in compliance with PSO guidance_ The attendees for enhanced care team review on 13/05 were not selected by the governor, who was in the chair, who left the invitations to the Segregation Unit_ A psychologist was not invited, contrary to local guidance. Health care was invited at the last minute with no notice to prepare.
0) The health care member attended with very little knowledge of the case. He did not know that there was an alcohol abuse history and did not discuss his personality disorder, possible prior diagnosis of schizophrenia or potential withdrawal problems _ He did not know of the Diazepam prescribing prior to admission or at Belmarsh. It was not clear that the review team had been informed of an admission by the prisoner that the recent ligalure was & serious attempt on his life_ A LISA form was completed at reception, giving details of Diazepam dependency; alcohol abuse, past history of schizophrenia, previous in patient psychiatric care and current antidepressants but this information was not available to the Review teams The listed Caremap areas for consideration were not all considered. Action to link the person to people who can provide support did not include his family (after the two minute reception call): Actions to encourage alternatives to self injury, to reduce emotional pain caused by practical problems, action to reduce vulnerability because of mental health problems and action to reduce vulnerability because of drug and alcohol problems were either not or inadequately considered. The governor agreed that he had not conducted a comprehensive careplan: g) Many of those actions required mental health assessment, which was not conducted before he died, which the expert said should have been done in 48hrs of admission, and not it was a really serious failure_ The last ACCT review did not consider whether or when it would be done. h) The last Review agreed the reduction of observations to hourly, without any information from mental health assessment: The governor had not seen the entry in the prison records that Mr Johnson was at high risk of impulsive behaviour causing accidental suicide. Had he known that; he would have asked for the results of the mental health assessment prior to downgrading his observations The expert was critical of Ihe decision to him in Segregation Unit; in the light of his vulnerability and health problems. It was not clear that all other options had been fully explored: this was not an item considered at the last ACCT Review: doing keep
_ (1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks t0 the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit; nor in the way in which members were asked to attend, nor the adequacy of caremap planning: The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manger and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit: Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
Responses
Action Planned
NOMS and NHSE will give further consideration to the extent to which screening processes should identify tobacco dependence and potential withdrawal issues. ACCT refresher training will reinforce that prisoners subject to ACCT procedures should be located in segregation units only in exceptional circumstances. (AI summary)
NOMS and NHSE will give further consideration to the extent to which screening processes should identify tobacco dependence and potential withdrawal issues. ACCT refresher training will reinforce that prisoners subject to ACCT procedures should be located in segregation units only in exceptional circumstances. (AI summary)
View full response
Dear Dr Harris Thank You for your Regulation 28 report addressed to the National Offender Management Service (NOMS), NHS England (NHSE), and the Governor of HMP Belmarsh: Equality, Rights and Decency Group responds to all Regulation 28 correspondence as We have the policy responsibility for suicide prevention and self-harm management, and for sharing learning from deaths in custody: Please accept this a5 a response from NOMS (including HMP Belmarsh) and NHSE, who has been consulted about this response: You identified a number of issues in your letters which have addressed below in the order which were raised_ NOMS and NKS England consider the Coroner's expert's opinion On the risks associated with tobacco withdrawal; Both NOMS and NHSE agree that, while comprehensive assessments are completed when prisoner is received into prison custody in relation to their health and risk of harm to Self and others, further consideration needs to be given to the extent to which screening processes should identify tobacco dependence and potential issues associated with withdrawal Currently, prisoners undergo a number of assessments on their arrival in prison custody: Prison Service Order (PSO) 3050 "Continuity of Healthcare for Prisoners, contains mandatory requirement that requires that an initial assessment of the healthcare needs of ali newly received prisoners is undertaken within 24 hours of first reception by an appropriately trained member of the healthcare team to identify any existing probiems and to plan any subsequent care. A health screen..takes place before the prisoner's first night to primarily detect: immediate physical health problems immediate mental health problems significant drug or atcohol abuse risk of suicide andlor self-har The policy requires that if immediate health needs are detected, the prisoner is referred to the appropriate healthcare worker or specialist team: In addition; in the week following first reception, prisoner must be ofiered & general health assessment This assessment is equivalent to primary care assessment when registering with new practice the community. Such assessments are not standardised, however the general health assessment should act as an opportunity for: gathering further medical information checking how the prisoner is settling in health education they every
providing information health promotion As you will recall from evidence at the inquest, second reception review %f the Prisoner s smoking habits andehow fanyoigareteestibe sheeeriokerclaies She Prisoner is asked whether heigheanishencohGtop tsanokirgarndes beesed heiokos &daily: Smoking cessation programmes , which include the provision of to do so evcence acveraablerogevm risonec throcacoutthes Droveioimefin icofiody renacertrer evidence given explained how diazepam can be prescribed necessary to alleviate the effects of tobacco withdrawal Iiaaddition;Prison Service Instruction 74/2011 'Eariy days in custody reception in, first igetatiocusode ardinduction t0 custody : inciudes tne requiremenofor aneneiaiocreenirg in relation to the prisoner's mood; prisoner must_ be interviewed; in private if to discover &nd record any further immediate needs and risks, and possible_ about the_prisoner that may be relevant; particularly any other information Furthermore, it requires that "The PER during their first night in custody" Suicide & Self and any other available documentation including Warning Forms, ACCT documents and CSRA assessments; must Ing fxathered and the prisoner interviewed in Reception, to assess the risk of self-harm orhare to others by the prisoner, or harm from others NO1es caccepts that despite the above range of screening during the reception process, fuaheiconsideration needs to be given to identifying prisoners fornghor tObaccowvithorawai may give rise to an increase in suicidal feelings or self-harm, and to develop the" given to prisoners who do not have access to tobacco, or to the amount would support Tely or NOMS is currently working with healthcare partners to develop they normally includes an appropriate level of screening, to ensure a care pathway, that is available but in that when tobacco is not available, or it more limited supply than the level are used to (because inited riundslaccess to prison shop}: that the relevant healthcare provderuensuees' that appeopeate support including Nicotine Replacement Therapy is available VThs ierrecognised as especially important in cases of poly substance users and those with mental health issues. Ireadditionp Vou WIl be interested t2 know that the Offender Health and Tobacco Cessation Teamseat Public Health England (PHE) are currently working on guidanceOioaCrsonsintine management of people with nicotine addictions_ As this guidance is not yet completed, PHE recommends that healthcare providers responsible for the assessment and treatment of tobacco withdrawal follow the NICE Public Health Guidance (PH45) on Tobacco Harm Reduction; which recommends that When tobacco is notavailable; Or itOi avaiaabe barin more limited supply that Nicotine Replacement Therapy is made available to supplement tobacco use. Facilitating access to extra nicotine can prevent users experiencing nicotine withdrawal and the side effects that this may cause: HMP Belmarsh review the areas of concern regarding the implementation of ACCT, that were raised during the inquest ACCLcase reviews National policy contained within PSI 64/2011 Management of prisoners at risk of harm to Self; to others and from Others (Safer Custody)" reminds staff of the mandatory requirement that ACCT-case reviews "Be multi-disciplinary where possible": Colleagues at HMP Belmaesh have . confirmed that the Goveror and all managers (including custodial managers and sudervising officers) Will attend further ACCT Case Manager refresher traininageparerta underline the importance of a multidisciplinary attendance at case reviews,andgthen need to seek contributions relevant departments, including healthcare staff and mental health the the help The Harm they they have from from
professionals This refresher training will commence this month and is expected to be completed by October 2014_ Initerms of attendance at ACCT case reviews; the policy recognises that The ACCT del operate more effectively # there $ continuity in ineeafendanceaf steef Aror relecant departmentsservices For example, if education is seen as & relevant department to attend the review; then every efiort should be made to ensure the samee memberzotneat ateredd the releiews; likewise with healthcare input. The Enhanced Case RevieweTeamtaill invote tal relevant disciplines and include more specialists and higher level of operational management than typical ACCT Case Review Team. Colleagues at Belmarsh have Tfirced that the refresher training will remind al managers tnataheadofany planner tbeaticCT Case Manager will undertake 3 handover with the new Case Manager a theovew; locatiorelandihe importance Di both ACCT Case Managere aftendingethearagereviehe preor feere relocation Will be reiterated, In addition, Case Managers will aiso becremindeevoPthe reed to gather all relevant information and to allow those attending ACCT case reviews rte review ACCT and any risk related information SystmOne) which Review Team need to be may possess (for example, on aware Of_ rithinethe ACCT process; the ACCT Assessor is expected to gather and review all available risk related information including that contained within the NOMIS notes, the F2050 (prisoners core record): and any recent ACCTs etc to inform the assessment All relevant risk information should be recorded within the ACCT, and attendees at the first ACCT review and subsequent case review meetings are expected to beeamiliarewitht he contents Of the ACCT; You will be aware that the Prisons and Probation Ombudsman that a local protocol was devised to ensure that information recommended custody and healthcare staff, and as a result members ofathe was shared between safer now record interaction with prisoners mental health in-reach team within the ACCT subject to on open ACCT both o SystmOne and document Case Managers have been reminded of the need to follow up hay beentalhealth referrals and are now required to follow up any referralse ensurionat? has been received and actioned this will also be addressed in current ACCT refresher Roining7 therocal policy %n Suicide Prevention (which is auertohee crerieguec On Tofrearer
2014) and a Notice to Staff to be issued on 3 March 2014. National policy requires that staff ensure that a case manager or representative from the receiving residential unit Is invited to attend a case review ahead of a planned relocation Withincthe prison the purpose of Which [s to ensure that all relevant informatior ardociakos shared and understood_ ACCI CAREMAPS Chapter 5 of PSI 64/2011 sets out the purpose of the ACCT case review which include: Consider and record progress against the initial CAREMAP; and the prisoners general welk- being; Consider whether the prisoner exhibits any additional needs which may require the CAREMAP to be updated; Discuss with the prisoner the meaning of any act8 of self-harm and options for alternative coping strategies Celleongues at Belmarsh have confirmed that ACCT case managers Will be reminded during theiongoing ACCT refresher training and in the updated local policy of the requirementih9 review the CAREMAPS at each case review and record the manager Who is responsible for each action and who is required to feed back at tne next case review. the they the the
A review of the records on SystmOne and the CAREMAP should have highlighted the fact that Mr Johnson had been referred for a mental health assessment but this had not been completed_ Location _in the segregation unit Policy allows prisoners subject to ACCT procedures to be located in the segregation unit in exceptional circurstances: The reasons must be clearly documented in the ACCT Plan and include others options that were considered but discounted" . In Mr Johnson's case, staff in the healthcare centre were concerned that Mr Johnson had become aggressive, and was threatening to damage and "kill someone" if he remained there_ Staff were concerned that he therefore presented danger to other patients, and his perceived attempt to assault Governor led to his relocation in the segregation unit While it is apparent that the Governor who authorised the segregation was not aware 0; Mr Johnson's ACCT or the potential triggers when he was relocated from the residential unit to the segregation unit; his risk was recognised by the Nurse completing the initial segregation safety algorithm (which requires confirmation of an open ACCT, as well as signs that they are acutely unwell) and accepted by the Governor. The reasons for him relocated to the segregation unit were documented by those attending the enhanced case review team who (as the PPO reported) thought he should remain there due to the outstanding charges (concerning the damage to his cell his attempted assault on the Governor) , and aiso because he was permitted to smoke there, which case review team recognised remained an extremely important concern to him: It is acknowledged in policy and accepted by colleagues at HMP Belmarsh that prisoners who are subject to ACCT procedures should be located in segregation units only in exceptional circumstances, and that this point will be reinforced during the ongoing ACCT refresher training hope you find this letter helpful:
providing information health promotion As you will recall from evidence at the inquest, second reception review %f the Prisoner s smoking habits andehow fanyoigareteestibe sheeeriokerclaies She Prisoner is asked whether heigheanishencohGtop tsanokirgarndes beesed heiokos &daily: Smoking cessation programmes , which include the provision of to do so evcence acveraablerogevm risonec throcacoutthes Droveioimefin icofiody renacertrer evidence given explained how diazepam can be prescribed necessary to alleviate the effects of tobacco withdrawal Iiaaddition;Prison Service Instruction 74/2011 'Eariy days in custody reception in, first igetatiocusode ardinduction t0 custody : inciudes tne requiremenofor aneneiaiocreenirg in relation to the prisoner's mood; prisoner must_ be interviewed; in private if to discover &nd record any further immediate needs and risks, and possible_ about the_prisoner that may be relevant; particularly any other information Furthermore, it requires that "The PER during their first night in custody" Suicide & Self and any other available documentation including Warning Forms, ACCT documents and CSRA assessments; must Ing fxathered and the prisoner interviewed in Reception, to assess the risk of self-harm orhare to others by the prisoner, or harm from others NO1es caccepts that despite the above range of screening during the reception process, fuaheiconsideration needs to be given to identifying prisoners fornghor tObaccowvithorawai may give rise to an increase in suicidal feelings or self-harm, and to develop the" given to prisoners who do not have access to tobacco, or to the amount would support Tely or NOMS is currently working with healthcare partners to develop they normally includes an appropriate level of screening, to ensure a care pathway, that is available but in that when tobacco is not available, or it more limited supply than the level are used to (because inited riundslaccess to prison shop}: that the relevant healthcare provderuensuees' that appeopeate support including Nicotine Replacement Therapy is available VThs ierrecognised as especially important in cases of poly substance users and those with mental health issues. Ireadditionp Vou WIl be interested t2 know that the Offender Health and Tobacco Cessation Teamseat Public Health England (PHE) are currently working on guidanceOioaCrsonsintine management of people with nicotine addictions_ As this guidance is not yet completed, PHE recommends that healthcare providers responsible for the assessment and treatment of tobacco withdrawal follow the NICE Public Health Guidance (PH45) on Tobacco Harm Reduction; which recommends that When tobacco is notavailable; Or itOi avaiaabe barin more limited supply that Nicotine Replacement Therapy is made available to supplement tobacco use. Facilitating access to extra nicotine can prevent users experiencing nicotine withdrawal and the side effects that this may cause: HMP Belmarsh review the areas of concern regarding the implementation of ACCT, that were raised during the inquest ACCLcase reviews National policy contained within PSI 64/2011 Management of prisoners at risk of harm to Self; to others and from Others (Safer Custody)" reminds staff of the mandatory requirement that ACCT-case reviews "Be multi-disciplinary where possible": Colleagues at HMP Belmaesh have . confirmed that the Goveror and all managers (including custodial managers and sudervising officers) Will attend further ACCT Case Manager refresher traininageparerta underline the importance of a multidisciplinary attendance at case reviews,andgthen need to seek contributions relevant departments, including healthcare staff and mental health the the help The Harm they they have from from
professionals This refresher training will commence this month and is expected to be completed by October 2014_ Initerms of attendance at ACCT case reviews; the policy recognises that The ACCT del operate more effectively # there $ continuity in ineeafendanceaf steef Aror relecant departmentsservices For example, if education is seen as & relevant department to attend the review; then every efiort should be made to ensure the samee memberzotneat ateredd the releiews; likewise with healthcare input. The Enhanced Case RevieweTeamtaill invote tal relevant disciplines and include more specialists and higher level of operational management than typical ACCT Case Review Team. Colleagues at Belmarsh have Tfirced that the refresher training will remind al managers tnataheadofany planner tbeaticCT Case Manager will undertake 3 handover with the new Case Manager a theovew; locatiorelandihe importance Di both ACCT Case Managere aftendingethearagereviehe preor feere relocation Will be reiterated, In addition, Case Managers will aiso becremindeevoPthe reed to gather all relevant information and to allow those attending ACCT case reviews rte review ACCT and any risk related information SystmOne) which Review Team need to be may possess (for example, on aware Of_ rithinethe ACCT process; the ACCT Assessor is expected to gather and review all available risk related information including that contained within the NOMIS notes, the F2050 (prisoners core record): and any recent ACCTs etc to inform the assessment All relevant risk information should be recorded within the ACCT, and attendees at the first ACCT review and subsequent case review meetings are expected to beeamiliarewitht he contents Of the ACCT; You will be aware that the Prisons and Probation Ombudsman that a local protocol was devised to ensure that information recommended custody and healthcare staff, and as a result members ofathe was shared between safer now record interaction with prisoners mental health in-reach team within the ACCT subject to on open ACCT both o SystmOne and document Case Managers have been reminded of the need to follow up hay beentalhealth referrals and are now required to follow up any referralse ensurionat? has been received and actioned this will also be addressed in current ACCT refresher Roining7 therocal policy %n Suicide Prevention (which is auertohee crerieguec On Tofrearer
2014) and a Notice to Staff to be issued on 3 March 2014. National policy requires that staff ensure that a case manager or representative from the receiving residential unit Is invited to attend a case review ahead of a planned relocation Withincthe prison the purpose of Which [s to ensure that all relevant informatior ardociakos shared and understood_ ACCI CAREMAPS Chapter 5 of PSI 64/2011 sets out the purpose of the ACCT case review which include: Consider and record progress against the initial CAREMAP; and the prisoners general welk- being; Consider whether the prisoner exhibits any additional needs which may require the CAREMAP to be updated; Discuss with the prisoner the meaning of any act8 of self-harm and options for alternative coping strategies Celleongues at Belmarsh have confirmed that ACCT case managers Will be reminded during theiongoing ACCT refresher training and in the updated local policy of the requirementih9 review the CAREMAPS at each case review and record the manager Who is responsible for each action and who is required to feed back at tne next case review. the they the the
A review of the records on SystmOne and the CAREMAP should have highlighted the fact that Mr Johnson had been referred for a mental health assessment but this had not been completed_ Location _in the segregation unit Policy allows prisoners subject to ACCT procedures to be located in the segregation unit in exceptional circurstances: The reasons must be clearly documented in the ACCT Plan and include others options that were considered but discounted" . In Mr Johnson's case, staff in the healthcare centre were concerned that Mr Johnson had become aggressive, and was threatening to damage and "kill someone" if he remained there_ Staff were concerned that he therefore presented danger to other patients, and his perceived attempt to assault Governor led to his relocation in the segregation unit While it is apparent that the Governor who authorised the segregation was not aware 0; Mr Johnson's ACCT or the potential triggers when he was relocated from the residential unit to the segregation unit; his risk was recognised by the Nurse completing the initial segregation safety algorithm (which requires confirmation of an open ACCT, as well as signs that they are acutely unwell) and accepted by the Governor. The reasons for him relocated to the segregation unit were documented by those attending the enhanced case review team who (as the PPO reported) thought he should remain there due to the outstanding charges (concerning the damage to his cell his attempted assault on the Governor) , and aiso because he was permitted to smoke there, which case review team recognised remained an extremely important concern to him: It is acknowledged in policy and accepted by colleagues at HMP Belmarsh that prisoners who are subject to ACCT procedures should be located in segregation units only in exceptional circumstances, and that this point will be reinforced during the ongoing ACCT refresher training hope you find this letter helpful:
Sent To
- HMP Belmarsh
- National Offender Management Service
- NHS England
Response Status
Linked responses
1 of 3
56-Day Deadline
14 Feb 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
By a majority, the jury found that Mr Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13th May 2010 in the Segregation Unit of HMP Belmarsh
Circumstances of the Death
Circumstances related to initial screenings in lhe First Night Centre: The jury concluded that Mr Johnson died in part from serious failures within the prison system: His initial screenings within the First Night Centre failed to highlight the urgent need for a mental health assessment and did not ensure his medication needs would be met and failed to take appropriate heed of Adrian Johnson's exceptional dependency on nicotine, the single trigger recorded on the already open ACCT.
2. Circumstances related to ACCT Reviews: The jury found that the ACCT Review on the morning of 13th May 2010 was inadequately conducted; in the absence of clinical records, with no appropriate psychologist present as per HMP Belmarsh Suicide Prevention Policy and the omission of the solicitor's letter from the family, received into Health Care Unit on the 12/h May 2010. The reduction in the level of observations and relocation into a non-gated cell prior to securing the overdue mental health assessment amounted to neglect; On the balance of probabilities the ACTT Review failed to maintain adequate protection for a highly vulnerable inmate with a history of recent impulsive self harm Two out of ten jurors objected to the use of the term impulsive in the absence of any mental health assessment conducted). May being
2. Circumstances related to ACCT Reviews: The jury found that the ACCT Review on the morning of 13th May 2010 was inadequately conducted; in the absence of clinical records, with no appropriate psychologist present as per HMP Belmarsh Suicide Prevention Policy and the omission of the solicitor's letter from the family, received into Health Care Unit on the 12/h May 2010. The reduction in the level of observations and relocation into a non-gated cell prior to securing the overdue mental health assessment amounted to neglect; On the balance of probabilities the ACTT Review failed to maintain adequate protection for a highly vulnerable inmate with a history of recent impulsive self harm Two out of ten jurors objected to the use of the term impulsive in the absence of any mental health assessment conducted). May being
Action Should Be Taken
(1) NOMS and NHS England are asked to consider the expert opinion on the risks associated with tobacco withdrawal and consider whether any national initiative is required to include screening in the reception process, or issue appropriate guidance_ HMP Belmarsh health care is asked to be mindful of the identified risks and advice of Ihese bodies_ (2) HMP Belmarsh is asked to review the areas of concern that were raised in this inquest; in relation to the adequacy of the ACTT Review process and either take appropriate action or report on the steps taken already to address these areas_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.