Daniel Davey
16 May 2019 · Coroner Darren Salter · Oxford
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of healthcare attendance at ACCT reviews
“Healthcare attendance at ACCT reviews - This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews. This is a significant concern and it is not in accordance with local and national policy. | understand that there were occasions when prison staff requested healthcare attendance, but no one was available. The system of providing advance notification to healthcare about the date”
2. in possession medication risk assessment not reviewed after ACCT opened
“Reviews of 'in possession' medication risk assessments - The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. | heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. | was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK's”
3. prison officers unaware of in possession medication risks
“A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. | am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and”
4. lack of cell searches for stockpiled medication
“This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. | did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about this.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The lack of a process for following up non- attendance at the Reception Healthcare first night screening”
This report
“It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews.”