Michael Folley
21 Jun 2019 · Coroner Karen Harrold · Hampshire (Central)
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. use of carbonated paper PER form
“The current PER form uses carbonated paper and is a pilot system adopted by only two police forces in the UK. It has been in use for 2.5 to 3 years and a national working group has suggested moving towards an electronic system but this has not been implemented.”
2. missing SASH completion
“The suicide/self harm warning alert (SASH) at page 9 of the PER was meant to be completed if there was a risk of self-harm or suicide since arrest or within the last month. In other words, it was felt the relevant period to be considered was not just the current period of detention but also anything relevant within a month before arrest.”
3. inadequate GEOAmey engagement in PER
“the impression created was that GEOAmey staff do not actively engage in and contribute to the contents of the PER to highlight any information relevant to risk assessment irrespective of what source it comes from.”
4. missing call logging system
“The electronic PER had been checked and nothing was logged. There is no reason to believe s call was not made and it is of concern that there was no apparent system for logging such a call let alone action in the contents of her request.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“That in the reception process the SASH document is not identifiable to all relevant staff.”
This report
“The suicide/self harm warning alert (SASH) at page 9 of the PER was meant to be completed if there was a risk of self-harm or suicide since arrest or within the last month. In other words, it was felt the relevant period to be considered was not just the current period of detention but also anything relevant within a month before arrest.”
Identical hazardConfidence 0.90 · high
This report
“The electronic PER had been checked and nothing was logged. There is no reason to believe s call was not made and it is of concern that there was no apparent system for logging such a call”
Later report
“There is no system in place to ensure that information provided in telephone calls in relation to a prisoner's welfare is recorded.”
Responses
2019-0230-Response-by-CNWL-NHS-Trust.pdf ↗· Central and North West London NHS Foundation Trust
2019-0230-Response-by-Hampshire-Constabulary.pdf ↗· Hampshire Constabulary Police