State Custody related deaths

Noted (AI summary) HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform future risk assessments at HMP Thameside. HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform future risk assessments at HMP Thameside. Serco (HMP Thameside) details actions taken, including the introduction of MS Teams folders for data retention, enhanced security strategies with trained analysts, and the implementation of a bodyscanner, with learnings from the inquest shared with senior management. They will also share learnings of the inquest with the senior management team, with advice that where there is a suspected 'swallow' and absence of a positive bodyscanner result, they should re-locate to healthcare. HM Prison and Probation Service acknowledges the concerns regarding record keeping and data retention at HMP Thameside, confirms receipt of the prison director's response, and outlines the contract delivery indicators and monitoring processes in place.

Noted (AI summary) NHS England acknowledges the concerns but states that matters relating to interpreters, communication, and family engagement are for local response. Regarding risk assessment documentation, NHS England states that risk assessments are carried out in line with NICE guidance and templates are available within SystmOne. Birmingham and Solihull Mental Health Trust has begun a 3-month pilot to ensure a Consultant Psychiatrist attends MDT meetings at the prison each week. A risk assessment template has been added to the SystemOne software accessible to Trust staff, and is being rolled out with a dissemination plan to ensure completion. TPP acknowledges the coroner's concerns, explains the capabilities of SystmOne, and states that it is working correctly. TPP defers to NHS England and local commissioners regarding specific configurations and usage of the system for mental health assessments in prisons.

Noted (AI summary) NHS England developed a training programme for Adult Safeguarding in Secure and Detained Settings in conjunction with HMPPS and HEE. The response also mentions a Ministry of Justice NPS toolkit. HMPPS will review and develop the key work model to improve safety and reduce reoffending, including making it more flexible. HMP Guys Marsh introduced an assurance check for weekly case notes and a weekly multi-disciplinary meeting to discuss and share information regarding drug ingress, issuing Governor's Notices and harm minimisation guidance as needed. The response refers to the Director General's letter which outlines the actions being taken at HMP Guys Marsh, such as introducing a Buddy scheme, writing local guidance, introducing an assurance check, and a weekly multi-disciplinary meeting.

Noted (AI summary) NHS England commissions healthcare in prisons and ensures equivalence of care. They state that shortcomings in training have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level. All reports received are discussed by the Regulation 28 Working Group. All new prison officers receive first aid training covering moving individuals for CPR, and manual handling training has been updated to a digital format. eLearning is available to all staff.

Noted (AI summary) TPP explains how the SystmOne electronic patient record system tracks amendments to consultations, stating that users are informed when an amendment has been made, by whom, and when, and that the audit trail is readily accessible. HMPPS has implemented a training program on medical emergency procedures for staff, including the use of emergency codes and cell entry protocols. A joint training event with healthcare staff was also held to improve care for acutely unwell prisoners, and weekly safety intervention meetings were introduced. The Trust has implemented compliance audit plans for NEWS2, is undertaking joint training with the prison service on several topics, and holds daily handover meetings to discuss prisoner clinical issues.

Noted (AI summary) A memorandum of understanding has been put in place between healthcare and the prison regarding attendance of healthcare and all planned use of force interventions and healthcare staff are to be trained alongside prison officers. NHS England will request assurance from regional Directors of Commissioning that actions regarding the use of the PSA (proactive systematic assessment) vital signs tool have been implemented and evidenced by April 2023. They will also work with HMPPS on their review of PSO 1600: Use of Force, providing clinical leadership on section 6. HMPPS implemented a memorandum of understanding with the new healthcare provider at HMP Portland regarding the role of healthcare during use of force incidents. Whitewood furniture beds have replaced metal bedframes at HMP Portland. The Governor of HMP Portland confirms their involvement in the HMPPS response to the Regulation 28 report.

Noted (AI summary) HMP Lowdham Grange has updated its DIC checklist to include the Oscar Journal. The use of ACCT tick sheets has been discontinued and all records are contained within the ACCT book. This is a response from a coroner to HMP Lowdham Grange, acknowledging the measures taken and suggesting further alignment with Chief Coroner guidance on disclosure.