Sarah Reed
28 Jul 2017 · Coroner Sir Peter Thornton QC · London (City)
This report repeats 3 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. untimely fitness to plead report preparation
“The deceased took her own life on 11 January 2016 in a single occupancy cell in C1, the mental health assessment unit, of HMP Holloway, North London. She strangled herself with a tight ligature made from bed linen.”
2. untimely fitness to plead assessment
“The jury concluded that the failure to conclude the fitness to plead assessment process in a sufficiently timely manner contributed to [the deceased]'s death.”
3. inappropriate observation frequency reduction
“The jury concluded that the decision to reduce the frequency of observations on [the deceased] at ACCT Review No.4 on 5 January 2016, six days before [the deceased]'s death, was inappropriate given the clear evidence of the deterioration of her mental state.”
4. incomplete ACCT document review
“The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”
5. inaccessible observation records
“The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be 'detrimental'. For example, many helpful observations about [the deceased]'s behaviour were recorded in the prison medical notes on SystemOne by doctors and nurses, but they were not accessible to prison officers.”
6. delayed CPA meeting
“The jury concluded that the delay in holding a Care Programme Approach (CPA) meeting was unacceptable. The evidence showed that a CPA Meeting for assessing a prisoner's long-term care should have been held within four weeks from reception. In this case it was held after nine weeks.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“better method must surely be devised to ensure that key clinical staff can access important information held electronically in a different NHS Trust”
This report
“The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be 'detrimental'”
Closely relatedConfidence 0.80 · moderate
Earlier report
“The ACCT document was not completed fully, did not accompany [the deceased] around the prison as it should have and not all appropriate individuals were invited to the reviews.”
This report
“(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”
Closely relatedConfidence 0.85 · high
Earlier report
“Ensuring that caseworkers are aware of and attend ACCT Case Reviews for patients under their care.”
This report
“The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”
Identical hazardConfidence 0.90 · high
This report
“The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be 'detrimental'.”
Later report
“SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT.”
Closely relatedConfidence 0.90 · high
This report
“(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”
Later report
“1.ACCT documentation and operation. The evidence disclosed serious difficulty in the recording, communication, and use of ACCT documentation.”
Responses
2017-0208-Response-by-NOMS.pdf ↗· His Majesty's Prison and Probation Service
Stated action · July 2017
“psychiatric reports. Work to review the procedures for obtaining and providing psychiatric reports is already underway, recognising the particular gap in relation to provision of reports for the purposes of fitness to plead. Following your letter to , Chief Executive HMCTS, I can confirm that in July 2017 HMCTS and the Judicial Office re- issued existing guidance from 2010 on this process, with the caveat that it is recognised that some information may be out of date. The Senior Presiding Judge has”
Stated action · early 2018
“The ACCT document is currently being redesigned with a view to its nationwide re- introduction in early 2018. As part of this redesign, we will consider your suggestion that a summary sheet of ACCT observations and conversations be included”
Stated action · July 2017
“learning bulletin (ACCT - Case Reviews, CAREMAPs and Levels of Conversations and Observations) was issued to all prisons in July this year. The bulletin reminded staff that ACCT review meetings must be multidisciplinary and must take place within the specified timescales. It further stated that that where any individual involved in the prisoner's management cannot attend the review, they must submit written contributions”
Stated action · summer 2018
“The PSI also states that unconvicted prisoners, such as [the deceased], must be allowed more frequent visits, and that establishments with a large number of unconvicted prisoners will require a more flexible system to enable rebooking of cancelled visits.”
Stated action
“Our service specification 'Manage the Custodial and Post Release Periods' is clear that all individuals in custody must have a resettlement plan and that the offender manager must ensure that external agencies are notified of a prisoner's release. All prisons are expected to adhere to this specification, but I know that it is not fully in place across the estate, and we are currently implementing a new model of offender management in custody.”
2017-0238-Response-by-CNWL-NHS-Trust.pdf ↗· Central and North West London NHS Foundation Trust
Stated action
“We have had a discussion with HMPPS who have agreed to provide a response regarding the procedure for cancelling visits.”
Stated action
“Procedures that any requests for reports are communicated to the Consultant as soon as they are received; this includes instructions from the Court, defence solicitors, Crown Prosecution Service and/or any other relevant external agencies including Probation Services.”
Stated action
“CNWL Offender Care has developed its own bespoke training for the management of harm and suicide in prison environments. This training forms part of our mandatory training list and is retaken annually by all staff. Across Offender Care, we are currently 94% compliant with this requirement.”
Stated action · 1 October 2017
“CNWL Offender Care has produced prison specific guidance highlighting these requirements which has been disseminated to all prison sites regarding expectations around CPA management, for comment. We expect this to be formally ratified as a new policy by 1 October 2017.”
Stated action · 1 October 2017
“A new discharge policy -”