Khalid Abiaz

Coroner's concerns

AI summary

A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.

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In the circumstances it is my statutory duty to make a report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 1. I heard evidence that following a review in 2015 changes to the ACCT document and process were piloted in 10 establishments in 2019 and this included HMP Swansea. As a result a revised ACCT version 6 and accompanying policy guidance was issued. This revised guidance makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. However, this requirement is not new. It was clear in my view from the HMP Swansea Suicide and Prevention Policy that was in place at the time of Khalid's death that a warning marker for suicide on a prison escort record ('PER') should result in the opening of an ACCT. The prison officer who saw Khalid first in reception gave evidence that he was an experienced prison officer with over 20 years-experience of working in prisons including 18 years at HMP Swansea. At the time when Khalid came into custody he was an ACCT assessor and remains in this role. He saw Khalid's PER which stated that Khalid had recently made threats to kill himself and was alleging mental health issues and he saw the NOEMIS transfer report which contained reference to historic ACCTs that Khalid had been on in custody and an act of cutting and ligaturing by Khalid 9 months before in December 2015. He did not open an ACCT but referred to the nurse who also did not open an ACCT. In his evidence the Prison Officer stated that if a prisoner came into custody now in 2022 with a warning on his PER stating that he has recently made threats to kill himself then this would not be enough to trigger the opening of an ACCT. This view is inconsistent with the mandatory revised ACCT policy quidance that I have set out above. This indicates that the system for trainina on

Responses

2 respondents

HM Prison Probation Service Central Government

15 Aug 2022 PDF

Action Taken

HM Prison and Probation Service rolled out ACCT version 6 across the prison estate and has produced and delivered training materials to support staff understanding. Fifteen staff members received the new training module, and the Governor has issued guidance on risk identification. The Governor has also requested that bank nurses are not deployed in the reception area of the prison. (AI summary)

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Dear / Annwyl Ms Heaven,

Thank you for your Regulation 28 report of 20 June 2022 addressed to the Ministry of Justice and the Governor of HMP Swansea, following the inquest into the death of Khalid Abiaz on the 13 September
2016. I am responding as Director General of Probation, Wales and Youth.

I know that you will share a copy of this response with Mr Abiaz’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

Following evidence heard at the inquest, you expressed concerns regarding prison and healthcare staff understanding of their responsibilities within the Assessment Care in Custody and Teamwork (ACCT) process, and the training provided to them. Thank you for bringing these concerns to my attention.

I understand that a response is also being provided by Swansea Bay University Health Board, the healthcare provider at HMP Swansea, so in relation to your concerns about healthcare staff I have limited my comments to explaining the training that HMPPS makes available to our partners.

As you note in your report, in July 2021 ACCT version 6 (v6) was rolled out across the prison estate. The revised form and guidance are intended to assist staff in providing high quality multidisciplinary care and support to individuals at risk of suicide and self-harm. Training materials and presentations have been produced and delivered across the estate in order to support staff in their understanding and delivery of the ACCT v6 process. This includes risk identification and how best to provide support to individuals.

Our policy (Prison Service Instruction 64/2011 Safer Custody) is clear that all staff who have contact with prisoners must undertake training on ACCT, and that refresher training must be provided according to local needs. This training forms part of the initial training undertaken by all Prison Officers. A new version of the training, which includes information about ACCT v6, has recently been produced and a programme is in place to ensure that all staff at HMP Swansea attend this as refresher training by November 2024. In the light of your report, the individuals about whom you have expressed specific concerns will be prioritised for this training, and for an upskilling session specifically related to ACCT v6 that has also been made available by the national Safety Team.

In order to improve the identification of risk in new prisoners and to build confidence in decision making around the opening of ACCT documents, fifteen members of staff who predominantly work in the reception area, induction wing, and healthcare received the new training module in July 2022. The Governor has issued guidance on risk identification and the establishment is scheduling additional training focusing on risks, triggers and protective factors for staff working in these key areas.

At national level, the ACCT case co-ordinator training has also been refreshed with the expectation that all previously trained staff will access the new training within three years.

HMPPS is committed to making ACCT training available to staff working for our partner organisations. At HMP Swansea, healthcare staff are encouraged to access all suicide and self-harm prevention training delivered within the establishment and the new modules will continue to be offered to them. The Governor has also formally requested through the Head of Healthcare, that bank nurses are not deployed in the reception area of the prison and are instead utilised in other areas within the establishment. This is to ensure that permanent nursing staff who have undertaken the ACCT training are allocated to the reception area to complete initial screenings.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised.

Swansea Bay University Hospital

15 Aug 2022 PDF

Action Planned

Swansea Bay University Hospital will ringfence two slots per ACCT training session for Health Board staff and will roster health staff to attend ACCT Awareness training as a priority. Health Board bank staff will no longer undertake the reception or screening function unless they are key trained. (AI summary)

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Dear Mrs Heaven,

Re: Inquest of Khalid Abiaz

I write further to your correspondence regarding the above and the Prevention of Future Deaths Report (Regulation 28) notification issued to the Health Board on 20th June 2022.

The Report was issued as a result of the inquest into Mr Abiaz’s death at HMP Swansea on 13th September 2016, which concluded on 16th June 2022.

You detail your concerns in respect of the bank nurse witness, who was employed by Swansea Bay University Health Board (SBUHB). The bank nurse at the time of Mr Abiaz’s death was employed by Bro Morgannwg University Health Board and undertook the first reception screening for Mr Abiaz when he arrived at HMP Swansea.

The report highlights your concern around the level and adequacy of the training on ACCT, which falls under the remit of the prison and thus will be addressed separately in the prisons response, but also concerns in respect of a bank nurse employed by SBUHB having access to the ACCT training.

Cadeirydd / Chair:

Prif Weithredwr/Chief Executive:

gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving

Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board

Although the response from the Prison will address the majority of the points you raise in respect of the adequacy of ACCT training, the Health Board has been working closely with the Prison and we are able to confirm that two slots per ACCT training session will be ring fenced going forward for Health Board staff.

Furthermore, Health Staff will be rostered to attend the ACCT Awareness training as a matter of priority. Updates on training numbers will be provided by the Health Care lead on a monthly basis via the Quality and Safety forum. Training will be a part of the mandatory induction for new Prison Health Board staff, and refresher training will be accessible to staff also, as and when the prison release dates.

In addition, the Health Board and HMP Swansea have agreed that Health Board bank staff will no longer undertake the reception or screening function unless they are key trained, have the necessary clearances and have undergone the appropriate training. The substantive prison staff will be detailed to undertake the reception functions.

To date, 8 prison health staff have undergone the version 6 ACCT training with 22 staff members remaining. The Health Board are also negotiating securing places for the medical staff on the training. This remains very much on our radar and as the national ACCT training dates are released, securing places will be a priority for the Health Board for those individuals who work in this setting.

I trust that the details included in this response sufficiently address the matters of concern raised in the report and provide you with the required level of assurance.

Please do not hesitate to contact us should you require any further information.

Report sections

Investigation and inquest

On 13th September 2016 an investigation was commenced into the death of Khalid Abiaz, a prisoner at HMP Swansea who died in his cell on 13th September 2016 after having tied a ligature around his neck. He was 40 years of age at the time of his death. The investigation concluded at the end of the inquest on 16th June 2022. The medical cause of death was: 1a pressure on neck (hanging) The conclusion of the inquest was as follows: An excessively elongated immigration process lasting 17 years has led to a significant amplification of Khalid's well documented mental health and housing issues. This cycle of a lack of adequate housing to keep him safe and erratically prescribed medication would have had a negative effect on his mental health. At times where risks by agencies involved were identified there was a failure to ensure that Khalid had the relevant medication and housing to keep him safe. There was a systemic failure to consider historic assessment about his mental health; rather agencies focussed on current presentation with apparent disregard and curiosity about historical data. Khalid led a chaotic life and had a history of drug and substance use and had multiple contacts with Government agencies .. Khalid had demonstrated on many occasions threats to self harm and harm others which were well document on Government systems. An unsympathetic and desensitised penal system with inadequate access to this data held by relevant agencies and poor processes to ensure this data is reviewed and actioned probably led to a situation in prison of Khalid having the opportunity to take his own life. Khalid was at risk of suicide upon arrival at prison; the prison and nursing staff followed an inadequate process without proper consideration and communication of all relevant documentation and historical data that would have oresented additional information and enabled the risk to be further considered.

it is our belief that he intended to commit suicide

Circumstances of the death

The deceased was Khalid Abiaz Khalid was a Somalian asylum seeker with an outstanding asylum appeal who on release from immigration detention in July 2016 experienced homelessness and three attempts to take his own life following which he was detained on each occasion under
s.2 of the Mental Health Act 1983 (MHA). Khalid had a long history of mental health issues and had been assessed on 3rd August 2016 by a consultant psychiatrist as posing a significant risk to himself and others. On 8th September 2016, following a threat to kill himself in the context of trying to get prescribed medication at a medical clinic in Cardiff, Khalid was detained by South Wales Police ('SWP') under
s.136 MHA and assessed under s.2 MHA at University Hospital Llandough. Khalid was not considered as meeting the criteria for detention under s.2 MHA and so was released with no medication. On 10th September 2016 Khalid was arrested and charged by SWP in respect of the incident on the 8th September 2016. He was then remanded into custody and sent to HMP Swansea on 12th September 2016 with warning markers on his prison escort record for threats of suicide and self-reported mental health issues. An ACCT was not opened in reception and Khalid was found suspended in HMP Swansea by a ligature in the early hours of 13th September 2016.

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and to the followina Interested

Inquest conclusion

An excessively elongated immigration process lasting 17 years has led to a significant amplification of Khalid's well documented mental health and housing issues. This cycle of a lack of adequate housing to keep him safe and erratically prescribed medication would have had a negative effect on his mental health. At times where risks by agencies involved were identified there was a failure to ensure that Khalid had the relevant medication and housing to keep him safe. There was a systemic failure to consider historic assessment about his mental health; rather agencies focussed on current presentation with apparent disregard and curiosity about historical data. Khalid led a chaotic life and had a history of drug and substance use and had multiple contacts with Government agencies .. Khalid had demonstrated on many occasions threats to self harm and harm others which were well document on Government systems. An unsympathetic and desensitised penal system with inadequate access to this data held by relevant agencies and poor processes to ensure this data is reviewed and actioned probably led to a situation in prison of Khalid having the opportunity to take his own life. Khalid was at risk of suicide upon arrival at prison; the prison and nursing staff followed an inadequate process without proper consideration and communication of all relevant documentation and historical data that would have oresented additional information and enabled the risk to be further considered.

it is our belief that he intended to commit suicide

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