State Custody related deaths

Action Planned (AI summary) MPFT is reviewing the fence structure around the garden on Laurel Ward, with options including a full replacement fence or retrofitting an anti-climb dome; the Trust is also discussing ways to complete searches of the garden at set frequencies, such as bi-monthly, and these will be addressed through the Trust’s Health and Safety Committee for action and monitoring.

Action Planned (AI summary) HMP Garth has arranged for the Prison Maintenance Group to review all cells and remove unused television brackets, with completion expected by February 2021. They are also reviewing accommodation in other prisons and alerting Prison Group Directors and Governors to the concerns.

Action Planned (AI summary) The IMB will deliver training to all immigration detention IMB members by the end of 2020, and require it for all future members with refresher training every three years. The training will focus on monitoring those in separation, raising concerns, and responding to allegations of abuse. The Trust is developing robust educational pathways within Offender Care and will develop a “train the trainer” programme to enable local sites to provide mental health awareness training routinely. The Offender Care directorate is drafting guidance on when a patient should be referred to the mental health team, including conditions and symptoms and will be circulating it as a standalone document to all CNWL staff and to all partner agencies by the end of November 2020.

Action Planned (AI summary) Wiltshire Police is working with other forces and the South West Provider Collaborative to develop a Memorandum of Understanding regarding mental health pathways. Avon and Somerset Police, on behalf of the South West Provider Collaborative, has clarified out-of-hours admission processes and confirmed with providers that services are commissioned to admit patients out of hours if clinically indicated. They are also developing a Memorandum of Understanding, with key milestones including governance/agency approval by October 2020 and communication to stakeholders by November 2020. They consider the training action is directed towards the Prison Service alone.

Action Planned (AI summary) Cardiff and Vale NHS Trust has reviewed the records, processes, and systems related to the death, noting a difference between NHS Wales and England regarding GP record access for prisoners. They have recently gained funding for an IT data specialist to improve IT in the prison, with recruitment to be pursued once a workforce review is complete.

Action Planned (AI summary) NHS England and NHS Improvement are leading a project with HMPPS to implement inter-operability between SystmOne and NOMIS to improve information sharing; Phase one is delayed until August 2020 due to COVID-19 priorities, and Phase three is expected in 2021. The Safer Custody Zone at Dovegate was formed in 2019, to facilitate information sharing between prison and healthcare staff.

Action Planned (AI summary) Care UK has offered additional refresher ACCT training to all staff, to be provided by the prison within 12 weeks. They are also implementing a system to ensure senior oversight on ACCT and SASH training across all Care UK sites. Care UK has offered additional refresher ACCT training to all staff, to be provided by the prison within 12 weeks. They are also implementing a system to ensure senior oversight on ACCT and SASH training across all Care UK sites.

Action Planned (AI summary) NHS England published guidelines and supporting documents for Health and Justice Clinical Reviewers in Sept 2018 and has published an amended specification for the provision of mental health services in prison. Additional resources were provided to HMP Manchester for mental health staffing. HM Prison and Probation Service are rolling out improvements to the ACCT process and are increasing the numbers of safer cells available to governors, including at HMP Manchester.

Action Planned (AI summary) • The use of thromboprophylaxis to surgery has been relaunched and clarified to all pertinent staff, particularly the time period before which it should be withheld. • All speciality specific thromboprophylaxis guidelines are being reviewed.

Action Planned (AI summary) HM Prison and Probation Service will review and update lists of risks and triggers as part of replacing PSI 64/2011 with a policy framework on prison safety, considering the risks posed by remand status. They will also revise the Introduction to Suicide and Self Harm Prevention training.

Action Planned (AI summary) HMPPS is considering alternative vape devices, including one using vapourless valve technology, to mitigate risks associated with e-cigarettes in prisons, but is constrained by cost and commercial availability.

Action Planned (AI summary) 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. 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. 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.

Action Planned (AI summary) The Home Office will write to all parties in IRCs by the end of April 2019 to reiterate the requirements for sharing information on detainees being managed under ACDT procedures. They will use learning from the HMPPS pilot to improve suicide and self-harm prevention guidance and procedures.