State Custody related deaths

Action Taken (AI summary) The Department of Health and Social Care outlines national measures to improve urgent and emergency care, including funding increases for ambulance trusts, hospital beds, and discharge support. It also notes improved Category 2 ambulance response times nationally and in the NWAS region, and decreased patient handover times. Swansea Bay University Health Board has developed a Standard Operating Procedure for transferring individuals with mental/physical health needs into their care. They have also improved the service level agreement with a local GP practice, recruited additional GPs and implemented changes to the night shift pattern to alleviate staff workload. HMPPS has received assurance from the Governing Governor at HMP Cardiff that all staff are aware of emergency medical codes via the radio system. The Governor is also committed to encouraging staff to raise concerns about an individual's management and will discuss with the Head of Healthcare how healthcare staff can be empowered to do so.

Action Taken (AI summary) HMPPS provides Introductory Suicide Prevention Training for probation staff and has developed a 7-minute briefing on suicide prevention. They are also working closely with other government departments to ensure prison leavers can access healthcare and support, and are drawing together a holistic staff IPP guide.

Action Taken (AI summary) Practice Plus Group details changes including medicines management policies reviewed and updated, a new audit tool for medication administration, new roles for nurses to oversee patients on wings, and a process in place if patient might be stockpiling medication. HMPPS has provided training to staff regarding the ACCT process, established a Safety Intervention Meeting (SIM) and a Multi-Disciplinary Complex Case Clinic (MPCCC) for complex cases. They encourage prison and healthcare staff to report intelligence through the Mercury intelligence system and undertake First Aid needs assessments and training.

Action Taken (AI summary) HMP Lewes reviewed record-keeping practices, clarified responsibilities for welfare checks and clinical observations, regularly briefs staff on emergency codes, and reviewed hospital escort procedures. Custodial managers now oversee Code Blue/Red incidents, and the policy on emergency escorts is being actively reviewed.

Action Taken (AI summary) HMPPS has implemented a revised ACCT case management approach across the prison estate to improve support for prisoners at risk of self-harm or suicide. They are also developing a safety training package for staff which will improve understanding of suicide and self-harm prevention.

Action Taken (AI summary) The Forward Trust has drafted and implemented a new protocol on the 'Management of Non-engaging Service Users Protocol'. A dissemination and training programme has been facilitated, and the protocol has been added to Clinical Governance, Managers and Staff meeting agendas.

Action Taken (AI summary) Practice Plus Group implemented a new transfer process in November 2023 to ensure the safe transfer of patients, including a transfer document that includes future external appointments. "Medical Hold" will be utilised to ensure that patients booked for urgent or specialised treatments/appointments are not transferred until the appointment has taken place.

Action Taken (AI summary) The Home Office has implemented new commissioning and handling processes and established a Strategic Improvement Operations team within FNORC to log, review, and track recommendations from internal and external investigations, ensuring risks are managed consistently. They also use a specific form called ‘Request for Risk Information’ to request an OASys assessment. These are now centrally administered by the FNO coordination hub to ensure that there is a central referral point for the Home Office. The request is then sent directly to the relevant practitioner to action, or the team if the matter is not yet allocated. An escalation process that highlights responses that have not been received within 20 days has also been introduced. Practice Plus Group has implemented weekly and fortnightly meetings between healthcare management and prison governors to improve communication between agencies. They have also clarified the established process regarding concerns for a prisoner's safety, where officers should inform a member of the healthcare team if they are presence. HMPPS has re-issued a notice to staff at HMP Belmarsh clarifying procedures for unlocking cell doors during the night state, emphasizing preservation of life takes precedence. Additionally, learning from probation-involved inquests will be disseminated across the probation service, and included as part of the Offender Management in Custody (OMiC) model of working.

Action Taken (AI summary) HMP Exeter has introduced an assurance procedure for the ACCT process and allocated a supervising officer to conduct daily checks of observations. They have also received funding for two Band 4 ACCT safety 'Floorwalkers' who conduct upskilling sessions and displayed ACCT V6 observation posters.

Action Taken (AI summary) HMPPS issued emergency response guides and pocket cards to all prisons. Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in October, and the HMPPS National Health and Safety Arrangements for First Aid and Emergency Aid Manual was published and introduced in August 2023. Practice Plus Group has changed procedures to ensure cell sharing risk assessments are completed effectively, including long term conditions monitoring, and provide the HMP Pentonville prison team with a list of patients with epilepsy/seizures to ensure that custodial staff are also able to identify cell-sharing issues.

Action Taken (AI summary) HMP Aylesbury has improved staffing levels, expanded key work provision, appointed a Neurodiversity support manager, reviewed the adjudication tariff for drug-related incidents, and reconfigured the safety team. Nationally, a TV and radio advert has been launched to support recruitment.

Action Taken (AI summary) Nottinghamshire Healthcare NHS Foundation Trust has implemented several improvements, including drill-based NEWS2 training, clear escalation pathways, and additional resources to support the rollout of NEWS2 training. They have also improved processes for supporting staff through the inquest process, including additional training and support from the Medico Legal Team.

Action Taken (AI summary) HMPPS is improving staffing at HMP Swaleside through interventions across pay, recruitment and retention, including a colleague mentor scheme, Advance into Justice, Prison Officer ‘Futures’, the National First Time Officer scheme, locally targeted PR activity, a market supplement and a pay increase.

Action Taken (AI summary) Dyfed Powys Police informed all relevant staff of the omission in this case and instructed Custody Officers to specifically ask interviewing officers about information relevant to risk assessment. Investigators have also been reminded of their duty to inform the custody officer of any relevant information. HMP Swansea introduced a thorough ACCT assurance procedure with additional checks by custodial managers and senior management. Further ACCT training is being rolled out to all ACCT case managers at HMP Swansea, focusing on consistency in case management, information sharing, and record keeping.

Action Taken (AI summary) The First Aid Policy Framework is being re-issued with instructions on face shield use, requiring all first aid kits to contain them and for them to be monitored. Face shields have been purchased and added to first aid boxes at HMP Preston, and staff were notified.