Mr Midland — HMP Featherstone
Life-Threatening Incident
28 April 2016
Independent investigation into a life-threatening incident involving ‘Mr Midland’1at HMP Featherstone on 28 April 2016 The report of the independent investigation conducted by Dr Deborah Brooke into the life-threatening incident involving ‘Mr Midland’ at HMP Featherstone on 28 April 2016 is published here. Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison
Key Findings
The investigation found that HMP Featherstone experienced issues with inter-departmental communication regarding substance misuse, specifically inconsistent attendance by Security at Substance Misuse Meetings and a failure to consistently refer prisoners under the influence to DARS/Health Care. Furthermore, the prison delayed informing Mr Midland's family of his serious condition for six days, which was deemed unacceptable, and failed to conduct a formal investigation into the incident as required by policy.
Learning Points (3)
Learning Point 1
HMP Featherstone and the health care providers in the prison should explore how to maximize information-sharing between Health Care and Security so that both of these components of care can work together to reduce the ingress and use of illicit substances in the prison. This includes the completion of agreed actions in the Substance Misuse Meetings and the Security Committee Meetings.
HMPPS Response
A number of measures have been put in place at HMP Featherstone since the incident involving Mr Midland which address this recommendation. HMP Featherstone now has a Drug Strategy Team which is led by a member of the Senior Leadership Team (SLT) and is supported by a full time Band 5 Custodial Manager who works with other internal departments sharing relevant information. Drug Strategy meetings are held on a monthly basis and are attended by Healthcare, Inclusion and Security to ensure the sharing of information regarding ingress and use of illicit substances. The Drug Strategy action plan is reviewed during each meeting. Additionally, the Drug Diagnostics Support visit action plan, which was produced following a supportive visit by HMPPS Drug Strategy and Delivery in July 2021, is monitored. The SLT Drug Strategy lead also attends the monthly Security meetings to discuss any concerns raised. The prison has a healthcare dedicated response member of staff who attends every reported incident of a prisoner being found under the influence of an illicit substance. For all prisoners confirmed as being under the influence a psycho-active substance (PS) log is completed where the prisoner is monitored for a period of time for their safety. Additionally all prisoners found under the influence will have a case note entered on their NOMIS record. This is accessible to all staff/departments in the prison who have access to NOMIS, including security and healthcare. Where a prisoner is confirmed as being under the influence this information is recorded on the prison’s Daily Briefing Sheet, which is used to share information with staff in the morning briefings. These briefings are attended by a number of departments, including healthcare, residential, safer custody and security, which has increased the sharing of information about the use of illicit substances in the prison. Every prisoner who is found under the influence of illicit substances at HMP Featherstone will be visited by a member of the Inclusion team within one or two days of the incident. The Inclusion Team offer support, talk about the dangers of taking illicit substances, review medications and consider medications at the weekly Safer Prescribing Meeting. Every day the operational briefing is reviewed by Practice Plus to ensure that no prisoners who have been found under the influence have been overlooked. Additionally the Safer Custody and Drug Strategy teams maintain a log of all occasions of PS misuse. This is used to identify any trends across the residential units and/or PS use by individual prisoners so that the prison can take appropriate action. For example, prisoners who are heavily involved in drug misuse will be considered for a Drug CSIP (Challenge Support and Intervention Plan) which provides a multi-disciplinary approach to support them.
Learning Point 2
HMP Featherstone should review its procedures so that families are informed of a prisoner’s illness with a minimum of delay.
HMPPS Response
In order to ensure that the prison holds up to date next of kin (NoK) details, the Safer Custody Department regularly checks with prisoners to ensure that the correct NoK details are recorded on NOMIS. HMP Featherstone engages with the NoK or nominated person when a prisoner is either terminally or seriously ill through the Family Liaison (FLO) protocol. Since 2018 there has been a Memorandum of Understanding (MoU) in place between Practice Plus and all services at HMP Featherstone in relation to information sharing. The MoU was reviewed and republished in November December 2021. Where a prisoner is either terminally or seriously ill Practice Plus will inform the prison and an FLO will be appointed by the prison to make and maintain contact with the allocated NoK. The appointed FLO will ensure accurate and comprehensive contact logs are maintained regarding any family contact. HMP Featherstone has two members of staff currently trained as FLOs. A further four members of staff have expressed an interest in this role and will be given relevant training at the earliest opportunity as HMPPS increase training opportunities.
Learning Point 3
HMP Featherstone should comply with the mandatory action contained in Prison Service Order 1300 – ‘Investigations’ that a formal investigation is completed when there is serious harm to any person.
HMPPS Response
An investigation will always be conducted where it is immediately clear that a person has sustained serious harm. The investigation conducted may not always be a formal investigation as described in PSO 1300 as there may be a more appropriate type of investigation to commission. Since PSO 1300 was introduced, HMPPS has developed further types of investigation so that senior managers may commission an appropriate investigation in the circumstances of individual cases. Information about investigations can be found in HMPPS policies PSI 64/2011 Management of Prisoners At Risk of Harm to Self, to Others and From Others, PSI 15/2014 Investigations and learning following incidents of serious self-harm or serious assaults and PSI 06/2010 - Conduct and discipline. In December 2019 and July 2020 HMPPS circulated a Senior Leaders Bulletin to remind senior managers of the need to consider the circumstances of the incident and the purpose of the investigation before deciding which type of investigation to commission. Senior managers were also signposted to the four HMPPS policies, including PSO 1300, that provide guidance to prisons about conducting investigations following such incidents.