East Sussex

Action Planned (AI summary) East Sussex Healthcare NHS Trust will implement measures for clinical teams to liaise with family members to understand how the patient typically expresses pain and what interventions have previously been effective, and a business case is being developed to explore additional support for the Learning Disability Nurse role.

Action Planned (AI summary) NHS England is working to enhance the sharing of patient information to and from VCSE and other independent sector providers commissioned by NHS organisations through Local Shared Care Records. The Getting It Right First Time Programme will also focus on risk assessment tools and family voice from 2024. The Langford Centre has implemented new procedures including mandatory recording of consent to speak with family, inviting family members to multidisciplinary meetings, and company-wide training updates on referral processes.

Action Planned (AI summary) Sussex Partnership NHS Foundation Trust will discuss changes made by East Sussex County Council with their Deputy Chief Nurse to ensure the Trust's doctors working as independent s.12 doctors are informed of ESCC's changes in practice and to identify any difficulties with information access processes. East Sussex County Council updated their Mental Health Act referral and Risk Assessment Forms to include a section on dynamic risk assessment, arranged yearly risk management training with Brighton University for AMHPs, and updated the AMHP warranting and re-warranting process.

Action Planned (AI summary) NHS England is providing targeted funding to STPs for multi-agency suicide prevention plans. The South East region suicide prevention lead is working to raise awareness regarding ‘shamanic hallucinogenic drugs’ and NHSE/I will share any learning generated by the South East regional team nationally.

Action Planned (AI summary) The Forward Trust provides substance misuse services at HMP Lewes and has a protocol for opioid overdose, with staff trained in naloxone administration. NHS England has developed a quality assurance framework to ensure quality standards are met in secure estate establishments and discussed concerns at the HMP Lewes Quality Board. HMPPS is preparing a pilot project to train prison staff in a number of prisons in the north of England to administer naloxone, and is considering the use of alternatives to intramuscular naloxone, such as nyxoid.

Action Planned (AI summary) The DHSC refers to the National Prison Partnership Board, which published a Principle of Equivalence in October 2019 to ensure equitable healthcare outcomes for prisoners. NHS England and NHS Improvement have taken steps to review and strengthen its quality assurance and contract performance systems. Following the death, NHS England has moved to a single provider model for healthcare in prisons to negate communication issues and ensure a single database system. Care UK was awarded the contract in October 2019, with services being mobilized for an April 2020 delivery date and oversight via contract review meetings. HMP Lewes is committed to providing resources for external escorts to medical appointments and currently makes sufficient staff available for three external hospital escorts each weekday. There is a daily meeting between prison and healthcare staff at which important information is shared.

Action Planned (AI summary) The Department of Health and Social Care states that providers of healthcare services are responsible for the quality and safety of the care they provide and expects the healthcare providers at HMP Lewes to consider improvements. The National Prison Partnership Board published a Principle of Equivalence in October 2019. NHS England reports that it has reviewed its commissioning contract performance and quality assurance systems following the death. Improvements include a revised governance structure with a Quality Board and Serious Incident Panel, and the appointment of a dedicated Quality Assurance Team. HMPPS published the Prisons Drug Strategy in April 2019 and each prison has responsibility for reviewing their own local substance misuse strategy. A notice is now displayed in the control room to serve as a visual reminder to staff of the need to call an ambulance immediately upon receiving an emergency code and the prison also issues notices to all staff regularly to remind them of the importance of using the emergency codes correctly.