Steven Davidson

Dear Mr Simblet I write further to your Report to Prevent Future Deaths (hereafter Report) dated 21st October 2025 concerning the death of Steven Roy Davidson on 12th March 2024 at HMP Chelmsford. I am responding to this report on behalf of HCRG Care Group in my role as Regional Director. I would like to take this opportunity to express my deep condolences to Mr Davidson’s family and loved ones. HCRG welcome the opportunity to reassure Mr Davidson’s family, other service users and yourself that the concerns raised in the Report have been listened to and reflected on, and that HCRG is taking action to ensure we learn from Mr Davidson's death and continually improve the service we provide. I adopt the numbering in your report and respond below in turn.

1. Difficulty navigating SystmOne records SystmOne is the NHS electronic patient record system used in prison and custodial healthcare settings across the country. NHS North of England Commissioning Support (NECS) provides training and technical support for users of SystmOne, including system navigation, search functions and information retrieval. HCRG has amended its training provision so that all new staff will now receive structured SystmOne training as part of their induction, provided by NECS and recorded in the mandatory training schedule. This will include guidance on locating clinical information that may be stored in different parts of the system (see further below). Refresher training will also be provided to existing staff within three months and recorded in their personal training record. All agency staff will be required to confirm in writing that they understand how to navigate clinical records held in SystmOne and this will be recorded in the ShareDrive. Any long-term agency staff will also complete the same structured training as permanent staff.

HCRG Care Services Ltd, company number 7557877 registered in England and Wales at The Heath Business and Technical Park, Runcorn, Cheshire WA7 4QX Send any correspondence to the address at the top of this letter

2. Searching records made during previous prison stays All Practitioners conducting clinical assessments should, as part of good practice, review relevant patient history when undertaking reception screenings, mental health reviews or risk assessments. In this case, it appears that practitioners focused primarily on Mr Davidson's current presentation rather than reviewing earlier records in depth. HCRG will reinforce through clinical governance that risk-related history should be considered when assessing patients, and that in some cases this may involve searching beyond the default summary record view. To ensure that records are being reviewed appropriately, the existing monthly audit of clinical notes will now include specific checks as to whether practitioners have accessed relevant historic information when assessing risk. Findings from the audit will feed into governance meetings and quality and performance monitoring available to NHS England commissioners. Historic risk-related information from earlier custody periods, including 2012–13 (as was the case here), was recorded in SystmOne before the widespread adoption of structured clinical terminology such as SNOMED (Systematised Nomenclature of Medicine Clinical Terms). At that time, information was commonly entered as narrative notes, scanned correspondence or imported documents, rather than as coded events. These formats are held within the system but do not automatically appear in structured risk or summary views routinely used during reception health screens, risk assessments or mental health reviews. This has highlighted the importance of staff understanding when and how to access older or non-coded sections of the record where historic risk-related information may be stored. The adoption of SNOMED and structured clinical coding enables more recent risk-related entries to be recorded in a format that surfaces more reliably in summary and risk views. Training and governance measures will therefore be focused on ensuring that staff can interpret both coded and historic record elements when assessing risk.
3. Understanding and utilising SystmOne As described above, all staff with access to SystmOne will complete structured training provided by NECS, which will cover system navigation, use of search tools, and how to retrieve both coded and historic information from different sections of the clinical record. This training has been incorporated into induction programmes and is now included in the mandatory training schedule for existing staff. HCRG’s Performance and Quality teams are embedding SystmOne training into existing governance and supervision processes to ensure consistent and safe use of the platform. Staff may also contact the Performance and Quality Lead if further clarification is needed, either directly or via their line manager. As is usual practice, we will continue to work with the teams to understand their experiences and to continually improve our services both in response to incidents and as part of day-to-day operations.

HCRG Care Services Ltd, company number 7557877 registered in England and Wales at The Heath Business and Technical Park, Runcorn, Cheshire WA7 4QX Send any correspondence to the address at the top of this letter

While we are confident that this response addresses the points raised in your Report, we would welcome a further opportunity to clarify any points which you, or Mr Davidson's family, consider require it. Yours sincerel Regional Director for Specialised, Surrey and Luton HCRG Care Group