State Custody related deaths

Action Taken (AI summary) HMP Liverpool has reviewed sentence calculations and found no other miscalculated sentences. First aid training is being provided to all Custodial Managers who carry out orderly officer duties, and Operational Support Grade staff will also be trained.

Action Taken (AI summary) HMP Swaleside issued a notice to staff on 10 August 2015 setting out local procedure for welfare checks and requiring staff to sign to confirm checks have taken place. NOMS is compiling a learning bulletin for all staff on their intranet by the end of September.

Action Taken (AI summary) HMP Wayland published a Governor's Order clarifying the recording of medical issues occurring overnight and amended the Local Security Strategy to support this. They also introduced a new radio system with more radios for healthcare staff. HMP Wayland has issued a Governor's Order instructing staff to record medical issues during the night in the wing observation book and amended the Local Security Strategy to reflect this procedure. A new radio system has been introduced at HMP Wayland and all healthcare staff are now routinely issued with radios.

Action Taken (AI summary) HMP Frankland revised local contingency plans and re-issued instructions to staff following Sharon Butcher's death to ensure that staff do not delay in calling an ambulance in all cases where there are serious concerns about an offender's health. The local protocols provide clear guidance to all staff to ensure timely, appropriate and effective response to medical emergencies.

Action Taken (AI summary) NOMS states that first aid training is being implemented at HMP Coldingley, with custodial managers trained and monthly closedown sessions used for wider staff training. They also state that a recent Health Needs Assessment confirmed existing healthcare arrangements meet the needs of the prison population.

Action Taken (AI summary) Tower Hamlets Council details actions taken following a Serious Case Review, including maintaining social worker numbers and updating a protocol with the Youth Offending Service to clarify responsibilities when a young person receives a custodial sentence. They also highlight increased awareness among Social Work staff due to the Legal Aid, Sentencing and Punishment of Offenders Act 2012. Central and North West London NHS Trust (CNWL) describes its Health and Wellbeing Team's structure and processes, including mental health assessments and improved office space and IT access. They state that all clinical contact is recorded on Systm1, with line managers checking staff entries and annual record keeping audits to monitor documentation standards, and training provided to new team members for Systm1 use. Oxleas NHS Foundation Trust describes implementation of the CHAT tool for assessing new arrivals at HMPYOI Cookham Wood, with training and monitoring standards. They detail information governance training for staff and supervised medication dispensing procedures, including recording and reporting non-compliance. The Medway Youth Offending Service (YOT) describes actions taken in response to the coroner's concerns including ACCT training for the Resettlement Team, enhanced reviews overseen by a Governor, and submission of early release paperwork. They also detail procedures for initial planning meetings, maintaining contact, and final release meetings according to YJB National Standards. The Ministry of Justice outlines reforms in the Young People's Estate, including a standardised casework model, enhanced regimes, and changes to ACCT procedures. They detail night operating procedures and confirm that an information sharing protocol between relevant agencies at HMYOI Cookham Wood is being formulated.

Action Taken (AI summary) Care UK has re-briefed control room staff, created a crib sheet for ambulance calls, launched a publicity campaign on emergency response codes, and improved intranet information and signage. The National Medical Director clarified GPs' responsibilities regarding verifying death, and guidance/training is being developed to support decision-making in unexpected collapse or death cases.

Action Taken (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.