Mr Quartz — HMP Doncaster

NHS England has developed a suite of service specifications, which has been agreed by the Health and Justice Clinical reference group to ensure consistency of practice and adherence to NICE guidance throughout the secure estate. Local area team commissioners are using these specifications when procuring services, as well as working with providers that are not on the new specifications to work through progress against them. A dedicated secure environment pharmacological lead has reviewed prison formularies and prepared revised guidelines for the use of antipsychotic medication. NHS England is currently consulting on revised guidelines for medicines optimisation. NHS England is committed to commissioning healthcare in prisons that is of equivalent standard to that provided in the community. It embraces the ‘Parity of Esteem’ agenda which dictates that mental health requirements are recognised to be as serious as physical health needs and receive an equivalent response. Where mental health need is acute, an enhanced response is provided. NHS England will seek the advice of the Health and Justice Clinical reference group on how best to implement this recommendation and whether this requires work in addition to that described above. This recommendation has also been shared with NHS Wales.

HMP Doncaster has a system in place to record all prisoners’ next of kin (NOK) details in reception and on the induction wing. Posters and reminders to prisoners are displayed on wings to encourage prisoners to notify staff of any changes in their NOK. The safer custody department also carry out regular checks of NOK details for those prisoners that are on an ACCT. Where prisoners fall ill due to general ill health or self-harm the safer custody manager / department will obtain the prisoner’s wishes on who they would like to be contacted. In any event where the prisoner is unable to communicate their wishes, the prison will contact the prisoners NOK or nominated person.

NOMS policy is that the decision to apply restraints to a prisoner during a stay at outside hospital, or on escort to hospital, is risk assessed on a case by case basis. The application of restraints must at all times be proportionate to the assessed security risks and balanced by considerations of care and decency for the prisoner. The risk assessment must be kept under regular review to take account of the prisoner’s changing clinical condition, treatment being received and any input from healthcare professionals. Any deterioration in the prisoner’s clinical condition or the intensity of the treatment that they are receiving must trigger an automatic review of the level of restraint necessary. In the event of a patient’s health deteriorating while at outside hospital, staff must contact the prison without delay and seek advice on the level of restraint required in such circumstances. NOMS has recently reminded establishments of the procedures to be followed.

NHS England is rolling out the ‘Through the Gate’ initiative across the North West secure estate. This ensures that work on substance misuse undertaken within the secure environment is continued in the community as part of the prisoner’s release plan, thereby providing continuity of care. This recommendation has also been shared with NHS Wales.

NHS England has reviewed the nature and quality of psychiatric and psychological assessments in prisons, and will be including them in a suite of service specifications that are designed to ensure consistency of practice throughout the secure estate. The second generation IT system currently being devised by the Health and Social Care Information Centre includes a data gathering system. This will support record sharing between establishments, and allow access to community records. It is scheduled to be in place in 2016. Interim measures are being put in place to allow better integration of healthcare records to ensure appropriate care planning. NHS England is committed to identifying good practice and disseminating it across the estate. This recommendation has also been shared with NHS Wales.

NHS England has developed a single operating model for managing and reviewing Serious Untoward Incidents and Deaths in Custody. There are critical lessons to be learned in reviewing all such matters and as a single organisation NHS England is able to map and manage trend data and respond accordingly. It is critical that risk assessments are appropriate, well documented and reviewed. All those displaying risk triggers will be managed through appropriate planning regimes. Prisoners identified as being at risk of self-harm are managed using the ACCT (Assessment, Care in Custody and Teamwork) process. This is a multi-disciplinary care planning process that draws on mental health assessment and services where appropriate.

All newly arrived prisoners into an establishment must currently be assessed as part of the reception health screen process to determine whether they are at risk of suicide or self-harm, and whether or not an ACCT plan should be opened, or an existing ACCT continued. If a prisoner is identified as being at risk of harm to self, or has committed an act of self-harm, staff must open an ACCT plan. The subsequent personal assessment, case review and production of a CAREMAP to address identified risks and to support the prisoner through their crisis is an integral part of the care planning process. The ACCT plan must only be closed once all the CAREMAP actions have been completed and the Case Review Team judges that it is safe to do so in that the risk posed by the prisoner has significantly reduced. There will be a post-closure interview which will review the CAREMAP and the progress made by the prisoner since the ACCT was closed. A decision to re-open the ACCT, hold further reviews or store the closed ACCT in the core record will then be taken. Prison NOMIS (the national database of offender information) can be used to record any information relating to a prisoner, including any triggers that may identify a potential risk to the prisoner.

If a prisoner is identified as being at risk to self and is the subject of an open ACCT plan then identified triggers must be reviewed as part of the case review process and staff in contact with the prisoner made aware of them. More broadly, and outside of the ACCT process, PSI 64/2011 Safer Custody contains a chapter about risks and triggers. It identifies a number of potential triggers which may increase risk of harm to self or others. All staff who have contact with prisoners must be aware of the triggers that may increase the risk of suicide, self harm or violence and take appropriate action. PSI 64/2011 recognises that not all triggers are identifiable and predictable, such as anniversaries. The existence of a trigger may not necessarily increase a prisoner’s risk. However, staff will remain alert to the changes in a prisoner’s risk and act when appropriate. ACCT case reviews are held at a frequency determined by the case review team and will consider whether the prisoner exhibits any additional needs which may require the CAREMAP to be updated. The Triggers box will be updated if new information arises.

In respect of the first point raised, Governor/Directors must ensure that staff who have contact with prisoners are aware of the procedures by which prisoners’ risk of harm to self, to others and/or from others is identified, assessed and managed. This includes training of healthcare professionals, volunteers and third party providers. The introduction to Safer Custody course covers record keeping as part of the training. The ACCT Plan travels to and from any location the prisoner moves to when he/she participates in activities (e.g. the prisoners’ workplace). This ensures that the receiving member of staff is informed of the prisoner’s risk status and is able to input to the ACCT Plan On-Going Record. In particular, they may record relevant information on the person’s mood, behaviour and situation. In respect of ACCT case reviews, NOMS promotes a multi-disciplinary approach to the care-planning system for prisoners and advocates inviting those staff that may provide helpful input at an ACCT review, for example, wing officer, the person who raised the initial concern, healthcare, and any other member of staff who has or will have contact with the at-risk prisoner and who can contribute to their support and care e.g. staff from Probation, Education, CARATS, psychology, etc. Whilst this review should be timely and not unduly delayed to ensure full attendance, the PSI also states that if invited participants cannot attend in person, exceptionally, they can provide a written account of their input.

Since the incident involving Mr Quartz, NOMS has rolled out Prison-NOMIS, which replaced the last prisoner case management system (LIDS) from May 2009 onwards. Prison-NOMIS allows for an electronic version of the prisoner history sheets which were used to list observations from wing staff. This system allows staff to record and update any comments they have following any meaningful encounter with a prisoner in the prisoner’s case notes. These comments are immediately available to all staff who have access to a prisoners record. The Prison-NOMIS system is available to all trained staff at an establishment, which may include chaplaincy and education staff, and HMPS HQ. Prisons should have arrangements in place for those staff that do not have access to Prison-NOMIS to contribute to case notes on a regular basis. This will ensure that information about an offender is as comprehensive as possible

HMP Doncaster’s health care provider has put in place a system for checking this equipment is in place. Weekly and monthly checks are carried out on the equipment and records retained by health care.