Greater Manchester Mental Health NHS Foundation Trust
NHS / Health Body
Action Taken
Healthcare staff at HMP Garth have been instructed to review and sign the welfare checklist document upon arrival at the wing to inform clinical decision making, with monthly assurance checks to be completed by the Primary Care Manager. A Standard Operating Procedure (SOP) will be co-produced with prison staff following the publication of national guidance from HMPPS. (AI summary)
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Dear Mr Rheinberg
Re: Marlin John Burrows (DoB 13/02/1977 DoD 16/08/2022)
Thank you for highlighting your concerns following the inquest of Mr Burrows, which concluded on the 29th of April 2024. On behalf of Greater Manchester Mental Health NHS Trust, I would like to offer Mr Burrows’ family our sincere condolences for their loss.
During the inquest you heard evidence that gave rise to the following matters of concern:
(1) The existing welfare sheet lacks clarity as to its exact purpose in terms of monitoring a prisoner whose health is of concern. (2) The sheet contains little guidance in relation to its completion. (3) Entries on the sheet made by prison staff appear not to be made known to attending medical staff. (4) The nature and operation of the sheet appears not to have been the subject of joint consideration on behalf of both Prison and Healthcare.
Following the conclusion of the Inquest, , Head of Healthcare for HMP Garth has met with the Governors of HMP Garth, , to address these concerns.
Our prison partners have informed us that nationally the picture has changed. His Majesties Prison and Probation Service (HMPPS) are developing national guidance for the management of people under the influence and that this process is currently going through consultation with Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL
Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.
their recognised trade unions. This national policy will address the concerns you raised in points 1, 2 and 4.
In respect of point 3 Entries on the sheet made by prison staff appear not to be made known to attending medical staff
All Healthcare staff attending prisoners have been informed that they must request the welfare checklist document on arrival at the wing, ensuring they have read and understood the entries to inform clinical decision making. This will be evidenced by them signing the sheet to say they have reviewed the information and their entry in the clinical record will state they have reviewed the welfare checklist and communicated with prison staff as part of their clinical assessment. In addition to this, assurance checks will be completed monthly by the Primary Care Manager who will review the welfare check sheets ensuring the attending staff have reviewed and signed the sheets as part of their assessment. This will be cross referenced with the clinical record to ensure that this information was considered when undertaking the assessment.
A Standard Operating Procedure (SOP) will be co-produced with prison staff following the publication of national guidance from HMPPS for prisoners who present as under the influence. This SOP will be shared widely with colleagues across the prison. We would be happy to provide a copy of this document to your Coronial Office should you wish.
In addition, the Head of Nursing and Quality for the Health & Justice Division at GMMH will work with the Healthcare staff at HMP Garth to develop some training and awareness sessions for prison staff around the use of the welfare checklist and the associated guidance once the national policy is implemented.
Can I thank you again for bringing these matters of concern to the Trust’s attention. I hope our response has gone some way to address your concerns. If you have any further questions in relation to the Trust’s response, please do let me know.
Re: Marlin John Burrows (DoB 13/02/1977 DoD 16/08/2022)
Thank you for highlighting your concerns following the inquest of Mr Burrows, which concluded on the 29th of April 2024. On behalf of Greater Manchester Mental Health NHS Trust, I would like to offer Mr Burrows’ family our sincere condolences for their loss.
During the inquest you heard evidence that gave rise to the following matters of concern:
(1) The existing welfare sheet lacks clarity as to its exact purpose in terms of monitoring a prisoner whose health is of concern. (2) The sheet contains little guidance in relation to its completion. (3) Entries on the sheet made by prison staff appear not to be made known to attending medical staff. (4) The nature and operation of the sheet appears not to have been the subject of joint consideration on behalf of both Prison and Healthcare.
Following the conclusion of the Inquest, , Head of Healthcare for HMP Garth has met with the Governors of HMP Garth, , to address these concerns.
Our prison partners have informed us that nationally the picture has changed. His Majesties Prison and Probation Service (HMPPS) are developing national guidance for the management of people under the influence and that this process is currently going through consultation with Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL
Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.
their recognised trade unions. This national policy will address the concerns you raised in points 1, 2 and 4.
In respect of point 3 Entries on the sheet made by prison staff appear not to be made known to attending medical staff
All Healthcare staff attending prisoners have been informed that they must request the welfare checklist document on arrival at the wing, ensuring they have read and understood the entries to inform clinical decision making. This will be evidenced by them signing the sheet to say they have reviewed the information and their entry in the clinical record will state they have reviewed the welfare checklist and communicated with prison staff as part of their clinical assessment. In addition to this, assurance checks will be completed monthly by the Primary Care Manager who will review the welfare check sheets ensuring the attending staff have reviewed and signed the sheets as part of their assessment. This will be cross referenced with the clinical record to ensure that this information was considered when undertaking the assessment.
A Standard Operating Procedure (SOP) will be co-produced with prison staff following the publication of national guidance from HMPPS for prisoners who present as under the influence. This SOP will be shared widely with colleagues across the prison. We would be happy to provide a copy of this document to your Coronial Office should you wish.
In addition, the Head of Nursing and Quality for the Health & Justice Division at GMMH will work with the Healthcare staff at HMP Garth to develop some training and awareness sessions for prison staff around the use of the welfare checklist and the associated guidance once the national policy is implemented.
Can I thank you again for bringing these matters of concern to the Trust’s attention. I hope our response has gone some way to address your concerns. If you have any further questions in relation to the Trust’s response, please do let me know.