HM Prison and Probation Service

Action Taken (AI summary) Lancashire Constabulary is leading a multi-agency review of the MARAC process, testing new models for responding to cases in 'live-time', and is addressing the wider family impact of domestic abuse. They have also delivered DA and HBV/FMFGM training to probation officers and implemented 'Operation Encompass' with DA training to school staff.

Action Taken (AI summary) Care UK updated its Local Operating Procedure in February 2019 to ensure a member of healthcare staff attends planned ACCT reviews daily. In-possession risk assessments are completed at various points and random spot checks are undertaken to reduce the risk of stockpiling. The Safer Custody Governor is recommending awareness of in-possession medication risks is included in case manager training. HMP Bullingdon implemented a new ACCT case management system with a case manager assigned to each case. The prison issued guidance stating in-possession medication is a topic for ACCT reviews, with risk assessments informed by healthcare. A safety briefing on in-possession medication has been distributed and ACCT case manager training will cover stockpiling medication. The Trust has reminded staff to update Medication In Possession risk assessments, ensuring updates feed into the ACCT. Staff were reminded that changes in presentation regarding serious self-harm should trigger opening an ACCT. The case was reviewed with involved staff, and learning shared.

Action Taken (AI summary) HMPPS details actions taken including; NHS England Commissioners, Mountain Healthcare, and the liaison and diversion service have been informed of the process for contacting the prison healthcare team. The courts that serve HMP Bullingdon and the escort contractors (GEO Amey) have been reminded that safety concerns should be recorded on the Person Escort Record. Care UK provides details of actions taken including; Healthcare staff attending prison morning meetings, maintaining a register of staff who have completed SASH training and providing ASIST training to all patient-facing staff.

Action Taken (AI summary) Prison psychology teams can request access to patient's clinical records and have been informed how to gain access. A rewritten guidance document for staff addresses patients who are non-concordant with medication, referencing actions for staff during weekdays and weekends; it was circulated to staff in December 2018. HMPPS provides a Care and Management Plan for prisoners managed by the Managing Challenging Behaviour Strategy (MCBS). They are rolling out 'Working with Challenging Behaviour' training, have developed a toolkit to help staff meet the needs of those with Learning Disabilities and Challenges (LDC), and are opening a dedicated unit for prisoners with autism at HMP Wakefield.

Action Taken (AI summary) The plan to upgrade the cell windows has now been approved and is provisionally on Ministry of Justice programme for delivery in 2019/20. Additionally, a number of measures to reduce prisoner access to non-prescribed medication have been introduced including assigning responsibility for medication queue management to one person, marking the dispensary floor for security and privacy, using CCTV, providing staff with attendee lists, and implementing a medication management practice where certain drugs are dispensed by healthcare. Care UK provides healthcare services at HMP Guys Marsh. In response to concerns about drug use, they have provided first aid training by prison staff and sourced posters highlighting the risks of NPS. They state a commitment to implementing lessons across Care UK's services.

Action Taken (AI summary) Since taking over prison healthcare services in 2017, Essex Partnership University NHS Foundation Trust has implemented a robust documentary system for referral of prisoners to mental health care, including widening the availability of a referral form to all prison staff.

Action Taken (AI summary) Care UK has reflected on the inquest and reviewed healthcare processes, embedding Local Operating Procedures (LOPs) with senior management audits, to ensure relevant risks and triggers are identified and shared with the prison; additionally, prisoners admitted to the Substance Misuse Unit will remain for a minimum of two weeks, with senior manager and clinical lead reviews before any moves.

Action Taken (AI summary) All staff at HMP Bedford were reminded of the importance of considering all available information prior to changing a prisoner's location, with monthly checks to ensure accurate record keeping. Staff will refresh their knowledge of NOMIS and a standardized induction program for new staff will be implemented by December 2017.