Edwin O'Donnell
13 Jul 2017 · Coroner Andre Rebello · Liverpool & Wirral
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of access to PER form containing relevant mental wellbeing information
“During the course of the inquest into the death of [name redacted] (Ned) O'Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another”
2. missing documentation recording on C-Nomis leading to missed risk assessment
“The Court considers that in other cases important information in assessing risk could be missed if action is not taken to remedy these matters by making it a requirement that prison discipline staff record on C-Nomis all documentation received with a prisoner in particular - PER forms - SASH forms - Printed summaries from System One - Prescriptions”
3. probation staff lacking basic ACCT training
“The Court considers it important that the Probation service takes responsibility to ensure that (offender managers and supervisors) probation staff working within prisons all receive basic ACCT training”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr [name redacted] to HMP Pentonville did not accompany him to nurse reception screening.”
This report
“During the course of the inquest into the death of [name redacted] (Ned) O'Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.”
Responses
2017-0258-Response-by-HM-Prison-Probation-Service.pdf ↗· His Majesty's Prison and Probation Service
Stated action
“The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to the healthcare member of staff based there, ensuring that they have access to all the relevant information.”
Stated action · 2078
“The SystmOne record is also available to the receiving establishment on a terminal in the reception area. We are therefore confident that the system that has been introduced at Liverpool ensures that the relevant information is routinely available, shared with healthcare staff and recorded.”
Stated action · shortly
“the Head of Healthcare at Liverpool and a member of the prison's senior management team are meeting shortly to re-evaluate current practices and implement revised procedures to ensure that second health screenings take place within 24-48 hours.”
Stated action · twice monthly
“At Liverpool the training is being delivered at the 'Academy Training Days' which take place twice monthly.”