State Custody related deaths

Action Taken (AI summary) All reception staff at HMP Preston have been given a copy of PSI 07/2015 and made it an objective to read and comply; revised suicide and self-harm prevention training is being rolled out, prioritising reception staff; emergency boxes with resuscitation aids are on all residential units, and all staff with prisoner contact will be issued resuscitation aids by June; contingency plans have been amended to ensure staff are informed about the manner of all non-natural deaths. The prison and healthcare services have agreed that PER forms will be passed to the reception nurse as a matter of routine, who must then document within the SystemOne record that the form has been received and considered; they are exploring incorporating this check into the record system as part of the existing reception health screen template.

Action Taken (AI summary) Regular notices to staff are published, signs are displayed in all offices and information about emergency response procedures is included in the induction for all new staff; notices have been attached to all cell doors in the First Night Centre; the London and Thames Valley regional search team is currently recruiting additional dog handlers to increase the service provided to prisons in the region, including HMP Wormwood Scrubs, which will be provided with a total of seven dog handlers, with both passive and active search and patrol dogs.

Action Taken (AI summary) The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to healthcare staff and reception staff have been made aware of this process. The individual concerned has been reminded of the circumstances under which it is appropriate to open an ACCT, and suicide and self-harm training is being rolled out to all staff.

Action Taken (AI summary) A notice to staff was re-issued on 28 September 2016 reminding staff about emergency codes and ambulance requests; the local emergency code protocol has been distributed and displayed. The induction programme for new staff is being updated to include guidance on the local emergency protocol and all existing staff will receive a personal briefing.

Action Taken (AI summary) HMP Leicester reminded staff about conducting observations at unpredictable times, management checks are in place, ACCT documents are quality assured, the contingency plan was revised, and staff were trained to intervene quickly if the observation panel has been blocked.

Action Taken (AI summary) Following concerns raised, the Trust co-authored a procedure with HMP Lindholme to convey summary medical information to A&E departments during inmate transfers, and the procedure has been issued to staff and is now in operation; a review of compliance will be undertaken.

Action Taken (AI summary) Following a failure to issue a Code Blue, all night staff at HMP&YOI Rochester were issued copies of PSI 03/2013 and signed to confirm understanding. A Notice to Staff was issued and pocket-sized cards explaining the codes were ordered for all staff, and a defibrillator demonstration was provided.

Action Taken (AI summary) Healthcare staff have been reminded of the importance of full and contemporaneous notes, and training has been provided on substance misuse; clinical guidelines are being developed for substance misuse issues, including a treatment plan template on SystmOne. Posters are planned for discipline staff areas, and training will be repeated to prison officers on emergency code allocation. All staff have signed to confirm their understanding of the Emergency Code Protocol, and managers have verified their awareness. Pocket-sized cards explaining the protocol have been issued, and the protocol is displayed in prominent areas and explained to new staff during onboarding; the protocol has been an agenda item at team meetings, and the issue has been addressed by the Deputy Governor and the Governor.

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) 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.