Source · Prevention of Future Deaths

Saifur Rahman

Ref: 2022-0155 Date: 26 May 2022 Coroner: James Bennett Area: Birmingham and Solihull Responses identified: 2 / 2 View PDF

Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose significant ongoing safety risks.

Date 26 May 2022

56-day deadline 21 Jul 2022

Responses identified 2 of 2

Mental Health related deaths State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose significant ongoing safety risks.

View full coroner's concerns

1. Calling a “code blue”: the evidence revealed that the safety critical code blue call
– automatically triggering an emergency response - was delayed by up to 2 minutes. The evidence was inconsistent on whether the cell entry briefing included the identification of an extra officer with a radio, and why therefore an officer in full person protective equipment ran out of the cell and across the ward to where she had left her radio to call the code blue. Delayed code blue calls have been a repeated problem at HMP Birmingham despite it being raised by the Prison and Probation Ombudsman and coroners in earlier regulation 28 reports. My ongoing concern is that delayed code blue calls will continue, and consideration should be given to the effectiveness of training in light of the evidence given by the prison officers at the inquest.

2. Cell history: the evidence revealed that cell fabric history - including fabric changes, damage and repairs - is safety critical information. Information about the history of cell H3-15 was lost or unclear as it transversed control of the prison changing from G4S to national control in 2018-2019 and there was no prison master/central record. My ongoing concern is that HMP Birmingham does not currently have a master/central record of cell history and relies on Amey who have a national contract for cell fabric changes and repairs. The evidence was unclear on whether the prison would have access to this safety critical information if the third party contractor changed.

3. NHS annual risk assessment: the evidence revealed that the mental health trust assessors had historically only dip-sampled a selection of the 15 x 2 cells on health care ward 2 (physical health) and ward 3 (mental health). They did not record which cells had been visually checked and relied in part on second-hand information from the prison about cell fabric and design. There had not been effective communication between the prison and health care staff. Generally, the trust had 140+ buildings across its entire estate to assess, this was done by two members of the health and safety team, and the assessment of the health care unit at HMP Birmingham was expected to be completed over several hours on one day. I was provided with a verbal undertaking that the trust would now visually inspect all 15 x 2 cells annually. However, this relies exclusively on the co-operation of the prison who have competing tensions given the operationally dynamic and challenging environment, especially if cells are occupied during the assessment. My ongoing concern is that there is no formalised process between the prison and mental health trust to visually inspect each cell. It is recognised prisoners housed on ward 2 and 3 are at a much greater risk of suicide than the general prison population, and general public as a whole, and will spend a great deal of time unobserved in the 15 x 2 cells. Therefore, in my view, visually inspecting 30 cells is not disproportionate to the level of risk and is not comparable to assessing an outpatient building in the community. The dynamic and challenging environment means it is likely all cells cannot be inspected on one visit. Visually inspecting each cell therefore needs to be properly planned and resourced by both the prison and mental health trust and consideration needs to be given to a formal process.

4. Prison risk assessment: the evidence revealed that dynamic daily and weekly prison officer cell fabric checks did not identify the risks with cell H3-15. The evidence from the mental health trust was that as their risk assessment is annual and the environment on ward 2 and ward 3 is dynamic and can quickly change, the prison needs to undertake its own risk assessment. I was provided with a verbal undertaking that the head of safer custody will undertake the first annual prison cell risk assessment visually inspecting all 15 x 2 cells 6 months after the NHS risk assessment, and delegate twelve monthly thereafter, resulting in alternating 6 monthly risk assessments. My ongoing concern is that there is no formalised process and consideration needs to be given to how results of the prison risk assessment is communicated to, and acted upon, by the mental health trust.

Responses

2 respondents

BSMHFT NHS / Health Body

26 May 2022 PDF

Action Taken

BSMHFT states that it had already updated the sampling of cells under the Ligature Risk Assessment to enable greater coverage of cells from year to year, and to generate an audit trail for those cells which had been viewed in previous years. They have asked for a formal process with the prison to be placed on the agenda for the Local Delivery Board meeting. (AI summary)

View full response

Dear Mr Bennett,

Re: Prevention of Future Deaths in the inquest of Saifur Rahman (deceased)

Thank you for sharing the Prevention of Future Death’s report with us on 26 May 2022.

Whilst we recognise the value of such reports and are committed to making improvements to our service, we were disappointed to have received a report in respect of this inquest. As a Trust we had gone to great lengths to provide evidence during the hearing that we had taken lesson learning in respect of this inquest very seriously. We also evidenced that we had acted on all the aspects that had been found in the Serious Incident Investigation and issues which arose during the inquest itself, through both written and oral evidence.

NHS Annual Risk Assessment The Trust had already identified the sampling of cells under the Ligature Risk Assessment as an area for improvement and prior to the inquest had provided evidence that the assessment model had already been updated to enable greater coverage of cells from year to year and to generate an audit trail for those cells which had been viewed in previous years, During the inquest on 15 May 2022 you had raised a query as to whether every cell could be viewed each year. Previously this had not been considered to be proportionate partly due to the number of settings the Trust is responsible for assessing (which are not limited to outpatient settings and include a variety of mental health settings of varying levels of security) but also because the Trust is reliant on the prison to grant access to each cell which might not always be possible if, for example, the occupant is dysregulated or the cell has been contaminated or soiled. However, on 15 May 2022 evidence was given on behalf of the prison that they would in future ensure that Trust assessors would be granted access to every cell over a 1-2 day period and that they would commit to overcoming any limitation

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on accessing any particular cell. Having received this assurance the Trust were able to reconsider the proportionality of the assessment and confirm to you that in future years the Ligature Risk Assessment would view all cells provided that the prison provided access. Your report states that the Trust had given this as a verbal undertaking at the inquest. In fact the commitment to view every cell each year was provided in writing on 16 May 2022 by way of a signed and sworn witness statement from the Trust’s Head of Health and Safety and Regulatory Compliance who is directly responsible for the assessor team. The Trust had considered the request in light of the evidence heard at the inquest and provided a written assurance by the following day. In order for this reassurance to be given, the Trust did consider future planning and resourcing to ensure that this would be completed. This takes place each year and the risk assessments for the prison are part of the Audit schedule for the Trust. In respect of formalising the process with the prison, the Trust’s Head of Healthcare at HMP Birmingham has emailed the Local delivery Board to ask that this matter is placed on the agenda for the meeting on 16th June
2022. This will ensure that the process is formalised. Commissioners will also be present at this meeting.

Prison Risk Assessment I would like to draw your attention to the wording of the recommendation for the Prison on their Risk Assessments. You have stated ‘My ongoing concern is that there is no formalised process and consideration needs to be given to how results of the prison risk assessment is communicated to, and acted upon, by the mental health trust.’

This gives us some concern as the wording suggests that the Trust has some element of control or can take action on any Risk Assessment carried out by the Prison. It was agreed in evidence at the inquest that any actions developed within Risk Assessments carried out by either BSMHFT or the Prison, would need to be taken by the Prison and not BSMHFT, as the Trust has no control to make any repairs or fabric upgrades within the prison. The prison are ultimately responsible for any actions, although we also monitor these through regular meetings with the prison. I would be grateful if you can make any necessary amendments to this point as we consider it is misleading.

I would like to assure you that we have taken the findings of the Serious Incident report and the Coroner’s inquest very seriously and indeed had taken action to act on these, prior to the completion of the Inquest itself, as attested to in evidence.

If you require any further information at this time, please do not hesitate to contact us.

HM Prison and Probation Service Central Government

20 Jul 2022 PDF

Action Taken

HMPPS reports that HMP Birmingham has undertaken initiatives to maintain staff awareness of medical emergency procedures, including safety talks and signage. The Governor has reviewed the local medical emergency response code protocol to ensure up to date training for all staff which is currently in progress. A central record of cell fabric history has been implemented and the prison maintenance database has been updated. A formalised process for cell ligature risk assessments is underway with the Health and Safety team, in partnership with the NHS. (AI summary)

View full response

Dear Mr Bennett,

Thank you for your Regulation 28 report of 26 May 2022, addressed to the Secretary of State for Justice and the Chief Executive of Birmingham and Solihull Mental Health Trust. I am responding on behalf of HMPPS as the Director General of Prisons.

I know that you will share a copy of this response with Mr Rahman’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.

You have expressed concerns around the calling of emergency codes, the recording of cell maintenance, and ligature risk assessments in cells. I will address these concerns in the order that they have been raised.

Given the often traumatic circumstances in which staff are expected to call a medical emergency code, it is recognised that this issue is one that must be continually reinforced to ensure it is fully embedded and staff are able to respond effectively. At a local level, HMP Birmingham have undertaken a range of initiatives to maintain staff awareness of the procedures, including ‘pop-up’ safety talks run by the prison’s safety team which continue to be delivered during staff briefings, prominent signage that provides guidance, and the issuing of leaflets to all staff members.

Additionally, the Governor has reviewed HMP Birmingham’s local medical emergency response code protocol to ensure that staff training is a central focus and that all staff have up to date training, including refresher training for all staff, which is currently in progress.

At a national level new emergency response guides were issued to all prisons which set out the actions required of staff in a medical emergency, including all the circumstances listed in the PSI 03/2013 Medical Emergency Response Codes under which a medical emergency response code should be called. In 2021, all Prisons were also issued with a supply of emergency response pocket cards which were shared with staff. The cards provided an instant reminder of how to respond to a medical emergency. In March 2022, a further supply of the emergency response pocket cards were issued to Regional Group Safety Leads for them to share with their prisons.

The findings of this inquest have also been shared with the national Safety team so that further consideration can be given to the points you have identified when national policy is next reviewed and revised.

In relation to cell maintenance, a central record of cell fabric history has been implemented and all cell repairs and any changes to a cell being in or out of use is now recorded. The prison maintenance database, Planet FM, has also been updated and has the ability to print the full records for any cell and evidence that all required maintenance work is completed will be required before a cell is put a cell back into use. Cell maintenance is now also discussed weekly by the AMEY lead during the Governor’s morning briefing to ensure that prison staff are aware of any maintenance work that is in progress or completed in order to share any updates.

Finally, you have queried the process for cell ligature risk assessments following evidence heard at the inquest. This process has since been reviewed internally and the introduction of a formalised process is currently underway with the Health and Safety team, in partnership with the NHS. The prison will be accountable for visiting the cell six months after the NHS assessment to confirm that any obvious ligature points are identified and minimised as best as possible.

On a national level, HMPPS is undertaking a review of ligature-resistant cells, which will include an assessment of the cell standards and regular maintenance to ensure that they do not deviate from the required standard over time.

Thank you again for bringing your concern to my attention. I trust that this response provides assurance that the appropriate action is being taken.

Report sections

Investigation and inquest

On 2 February 2021 I commenced an investigation into the death of SAIFUR RAHMAN. The investigation concluded at the end of a jury inquest held between 9-20 May 2022.

Circumstances of the death

The jury’s factual finding: Saifur Rahman was a recognised drug user. It was reported that he was using mamba which contributed to the decline in his mental health. On the 16 November 2020, he was remanded at HMP Birmingham and on the 21 November he was admitted to the health care ward for a period of assessment. In early December he was diagnosed with Bi-polar disorder with mixed affective state and was treated with medication. Saifur Rahman's presentation on ward two was varied. At times he was amicable and would engage with others, at other times he was unpredictable and uncommunicative. He occasionally expressed odd beliefs and aggressive behaviours. However, he showed no self-harm or suicidal ideation. An A.C.C.T. was not considered necessary. In early January 2021 he was non-concordant with his medication. On 9 January he was moved to cell H3-15 due to damage and graffiti of his previous cell. On the 17 January, his unlock status was increased to custody manager plus three prison officers in full personal protective equipment. This was a consequence of his previous aggressive and anti-social behaviour. A relative telephoned the prison on 18 January, parties to the conversation report different accounts. However, it resulted in an application form for an additional number being added to Saifur Rahman's contacts. An officer presented the form at the cell and conducted a welfare check. The outcome of his last psychiatric assessment on 19 January was for Saifur Rahman to remain on healthcare, to record compliance with his medication and continue to monitor behaviour. The assessment raised no concerns regarding self-harm or suicidal ideation. Mr Rahman's presentation on the 20 January leading up to the incident raised no cause for concern. He was last seen alive at approximately 16:25 hours when he was delivered a meal through his cell door hatch. At approximately 17:00 hours during the medicine round, he could not be seen through the cell door hatch and he did not respond when called. The observation hole into the internal toilet recess had been damaged via a burn mark and crack. There was no evidence as to how or when this happened. The dome mirror was also missing, so it was not possible to see into the recess area. The prison officers expected to be assaulted on entering the cell, from the toilet recess. Therefore, unlock status was followed and cell entry occurred at around 17:13 hours. Mr Rahman was found

He was lifted, placed on the floor and found to be in cardiac arrest. The prison officers commenced CPR. From the evidence given, it is likely that cardiac arrest occurred between 16:37 hours and 17:10 hours. The code blue call was delayed by up to a minute, but this did not contribute to his death. Prison nurses arrived and assisted with CPR. A defibrillator was applied but detected no shockable rhythm. Paramedic arrived at H3-15 at 17:35 hours. Return of spontaneous circulation was achieved but he remained unconscious and was taken to City Hospital, arriving at 18:16 hours. He remained very unwell and despite continued treatment died on 23 January 2021. Post-mortem examination confirmed there had been a sufficient period of reduced blood and oxygen supply to the brain, resulting in irreversible injury. It is known that when commissioned H3-15 was intended for infectious prisoners who needed to shower in isolation. The shower was decommissioned but the shower head was left in situ. It is unknown when or why it was decommissioned. In November 2017 H3-15 was taken out of use following damage to the cell, including damage to the dome mirror and the bed. In July 2020 H3-15 began to be used again without the mirror. No explanation was provided as to why. The 2020 cell risk assessment conducted by the mental health trust did not identify the disused shower head in H3-15. The process was non-standard and conducted over the telephone due to Covid-19 restrictions. Following a post-mortem the medical cause of death was confirmed as: 1a Hypoxic/Ischaemic encephalopathy 1b External neck compression 1c . The jury’s conclusion: Saifur Rahman died from which caused external neck compression which led to hypoxic/ischaemic encephalopathy. Mr Rahman's intention when fashioning the was to commit suicide. There was a clear thought process in creating a from his

. Given his diagnosis of Bi-polar disorder with mixed affective state, he displayed impulsive behaviour and made rash decisions. This contributed to his intention in fashioning the . It was inappropriate to use H3-15, given it had a was not replaced after it had been damaged. The risk assessments conducted by the mental health trust were insufficiently recorded due to ineffective sampling methods, non-identification of cell differences and reliance on historical records. The prison weekly fabric checks conducted by custody managers were insufficiently recorded.

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Report details

Reference: 2022-0155
Date of report: 26 May 2022
Coroner: James Bennett
Coroner area: Birmingham and Solihull

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Jul 2022.

Sent to

Birmingham and Solihull Mental Health NHS Foundation Trust

Ministry of Justice

Source links

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Data: judiciary.uk under OGL.