Source · Prevention of Future Deaths

Saul Thomas

Ref: 2021-0423 Date: 21 Dec 2021 Coroner: David Reid Area: Worcestershire Responses identified: 1 / 1 View PDF

A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included in handovers between prisons, posing a risk of future deaths.

Date 21 Dec 2021

56-day deadline 15 Feb 2022 est.

Responses identified 1 of 1

Mental Health related deaths State Custody related deaths

Coroner's concerns

AI summary

A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included in handovers between prisons, posing a risk of future deaths.

View full coroner's concerns

(1) In the questionnaire which formed part of their conclusion, the jury found that an ACCT document should have been opened for Mr. Thomas at HMP Birmingham at some point after 11.5.19, and that a failure so to do probably caused or contributed to his death. I heard evidence from a senior member of staff at the prison that as many as a third of all staff at HMP Birmingham still do not have up-to-date training relating both to and to the ACCT process. I was also concerned to hear from one prison officer that he had had no ACCT training since 2014. Until such training is provided to all staff working at the prison, there remains a risk of similar deaths occurring in the future;

(2) In the questionnaire which formed part of their conclusion, the jury found that the unsatisfactory handover about Mr. Thomas provided by HMP Birmingham to HMP Hewell possibly caused or contributed to his death. I heard evidence from a senior member of staff at HMP Birmingham that (a) prison staff there should have alerted their counterparts at HMP Hewell to the fact that Mr. Thomas had been undergoing psychiatric assessment within the Inpatients Unit there; and (b) that this was still a concern which needed to be looked into. I was concerned to hear that, whilst this failing has been recognized by HMP Birmingham, no action has been taken to ensure that it will not be repeated. Until action is taken to ensure that handovers between prisons include such important information, there remains a risk of similar deaths occurring in the future.

Responses

1 respondent

HM Prison and Probation Service Central Government

14 Feb 2022 PDF

Action Planned

HMP Birmingham plans to train 80% of staff in suicide and self-harm (SASH) over the next six months, prioritizing high-risk areas and ensuring new staff receive SASH training; a new handover process is in place for prisoners transferring with healthcare needs. HMP Hewell delivered training to 205 staff in the latest version of ACCT in December 2021 and is working to train a larger percentage of staff. (AI summary)

View full response

Dear Mr Reid,

Thank you for the two Regulation 28 reports of 21 December 2021 following the inquest into the death of Saul Thomas at HMP Hewell on 19 May 2019, addressed to the Governors of HMP Birmingham and HMP Hewell respectively. 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 the family of Mr Thomas and I would 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 have raised two matters of concern: staff training in the Assessment, Care in Custody and Teamwork (ACCT) process (the system by which prisoners at risk of suicide and self-harm), and the need for effective handover procedures when prisoners transfer prisons.

HMP Birmingham have increased the capacity of their ACCT version 6 training, and now have a plan in place to train 80% of their staff in suicide and self-harm (SASH) over the coming six months. The training plan prioritises staff working in areas of the prison that are considered high risk, including the Care and Separation Unit (CSU), Healthcare Unit, Reception and the Reverse Cohorting Unit (RCU). To achieve this the Governing Governor has asked the Prison Group Director for additional training to be made available to reduce the number of staff requiring training. In addition, HMP Birmingham will ensure all future new staff will receive SASH training as part of their induction.

HMP Hewell have advised that in December 2021 alone they delivered training to a further 205 staff in the latest version of the ACCT. Despite having been impacted by COVID-19 and its restrictions, they are continuing to work through the backlog of staff ACCT training and over the coming months expect to have trained a much larger percentage of staff. The prison has 209 staff fully trained in SASH, and a further 66 currently working through the required training modules. By the end of March 2022 HMP Hewell will have a further two members of staff trained as SASH trainers, and therefore will be able to provide more training opportunities at HMP Hewell in order to speed up the delivery.

With regard to transfer procedures, a new process is now in place at HMP Birmingham for when prisoners who are being supported by healthcare, including mental health services, are being transferred to another establishment. As soon as it is known a prisoner is transferring, the healthcare team are required to make contact with the receiving prison. If this is not possible then the matter is escalated to the healthcare manager and duty Governor who are then required to ensure a handover takes place before they leave their shift. In addition to this, on the day of the transfer reception staff are required to call the receiving reception manager to notify them of a new arrival transferring from a healthcare unit. These actions will be recorded on the prisoner’s National Offender Management Information System (NOMIS) record and the new digital Prisoner Escort Record will also record any and all prisoner healthcare requirements.

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, and I would once again like to reiterate my sincere condolences to the family of Mr Thomas.

Report sections

Investigation and inquest

On 9.5.19 an investigation was commenced into the death of Saul Richard THOMAS, a prisoner at HMP Hewell who died in his cell at the prison on 19.5.19 having . He was 42 years of age at the time of his death. This investigation concluded at the end of the inquest on 10.12.21. The medical cause of death was:

The conclusion of the inquest was as follows: “Saul Thomas died as a result of

. It is not possible to determine what his intention was at the time he did this. See Questionnaire:
1. Was Saul's mental health adequately assessed and managed by healthcare at HMP Birmingham? NO
2. If NO to Question 1: (a) did a failure to assess and manage Saul's mental health at HMP Birmingham probably cause or contribute to his death on 19 May 2019? NO (b) If NO or CANNOT SAY to Question 2(a), did a failure to assess and manage Saul's mental health at HMP Birmingham possibly cause or contribute to his death on 19 May 2019? YES
3. Do you consider that an ACCT suicide/self-harm mitigation plan should have been opened at HMP Birmingham on or at any stage after 11 May 2019? YES
4. If YES to Question 3: (a) did a failure to open an ACCT on or at any stage after 11 May 2019 at HMP Birmingham probably cause or contribute to his death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 4(a), did a failure to open an ACCT on or at any stage after 11 May 2019 at HMP Birmingham possibly cause or contribute to his death on 19 May 2019?
5. Was the outgoing handover about Saul from HMP Birmingham to HMP Hewell satisfactory? NO

6. If NO to Question 5: (a) did that unsatisfactory handover probably cause or contribute to Saul's death on 19 May 2019? NO (b) if NO or CANNOT SAY to Question 6(a), did that unsatisfactory handover possibly cause or contribute to Saul's death on 19 May 2019? YES

7. Did HMP Hewell deal with the handover about Saul from HMP Birmingham in a satisfactory way? NO

8. If NO to Question 7: (a) did the unsatisfactory way in which HMP Hewell dealt with the handover probably cause or contribute to Saul's death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 8(a), did the unsatisfactory way in which HMP Hewell dealt with the handover possibly cause or contribute to Saul's death on 19 May 2019?

9. Was the mental health referral made by healthcare at HMP Hewell 2019 adequate? NO

10. If NO to Question 9: (a) did the inadequate mental health referral at HMP Hewell probably cause or contribute to Saul's death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 10(a), did the inadequate mental health referral at HMP Hewell possibly cause or contribute to Saul's death on 19 May 2019?

11. Was information shared and considered adequately by healthcare staff at HMP Hewell? NO

12. If NO to Question 11: (a) did inadequate sharing and consideration of information by healthcare at HMP Hewell probably cause or contribute to Saul's death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 12(a), did inadequate sharing and consideration of information by healthcare at HMP Hewell possibly cause or contribute to Saul's death on 19 May 2019?

13. Was Saul's mental health adequately assessed and managed by healthcare at HMP Hewell? NO

14. If NO to Question 13: (a) did the failure by healthcare to adequately assess and manage Saul's mental health at HMP Hewell probably cause or contribute to his death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 14(a), did the failure by healthcare to adequately assess and manage Saul's mental health at HMP Hewell possibly cause or contribute to his death on 19 May 2019?

15. Should an ACCT mitigation plan have been initiated by prison staff at HMP Hewell? YES

16. If YES to Question 16: (a) did the failure by prison staff at HMP Hewell to open an ACCT probably cause or contribute to Saul's death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 16(a), did the failure by prison staff at HMP Hewell to open an ACCT possibly cause or contribute to Saul's death on 19 May 2019?
17. Was Saul Thomas' death contributed to by neglect? YES

Circumstances of the death

In answering the questions “when, where, how and in what circumstances did Mr. Douglas come by his death?”, the jury found as follows:

“On 19/5/19 Saul Thomas died at HMP Hewell, in his cell.”

To clarify, Mr. Thomas was remanded into custody to HMP Birmingham, charged with a number of serious offences, on 15.4.19. This was his first experience of custody. He had a recent history of drug-induced paranoia, linked to his heavy use of cocaine, and whilst at HMP Birmingham was transferred to the mental health ward within the Inpatients Unit, so that his mental health could be formally assessed. During his time at HMP Birmingham, Mr. Thomas continued to express paranoid thoughts, particularly that other people were looking to harm him and that he would be killed. Following a court hearing on 16.5.19, he was transferred to HMP Hewell. Both prisons failed to ensure that HMP Hewell were made aware of the concerns over Mr. Thomas’ mental health and the fact that he was undergoing psychiatric assessment within the Inpatients Unit at HMP Birmingham before his transfer. Once at HMP Hewell, he was placed on an ordinary prison wing. It was recorded that he felt under threat, but didn’t know why. On the morning of 19.5.19 Mr. Thomas was found unresponsive in his cell at HMP Hewell, having . He was confirmed deceased some 30 minutes later.

Action should be taken

by conducting an investigation into the deficiencies and failures outlined above, and ensuring that appropriate training is provided to all relevant staff.

Inquest conclusion

“Saul Thomas died as a result of

. It is not possible to determine what his intention was at the time he did this. See Questionnaire:
1. Was Saul's mental health adequately assessed and managed by healthcare at HMP Birmingham? NO
2. If NO to Question 1: (a) did a failure to assess and manage Saul's mental health at HMP Birmingham probably cause or contribute to his death on 19 May 2019? NO (b) If NO or CANNOT SAY to Question 2(a), did a failure to assess and manage Saul's mental health at HMP Birmingham possibly cause or contribute to his death on 19 May 2019? YES
3. Do you consider that an ACCT suicide/self-harm mitigation plan should have been opened at HMP Birmingham on or at any stage after 11 May 2019? YES
4. If YES to Question 3: (a) did a failure to open an ACCT on or at any stage after 11 May 2019 at HMP Birmingham probably cause or contribute to his death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 4(a), did a failure to open an ACCT on or at any stage after 11 May 2019 at HMP Birmingham possibly cause or contribute to his death on 19 May 2019?
5. Was the outgoing handover about Saul from HMP Birmingham to HMP Hewell satisfactory? NO

6. If NO to Question 5: (a) did that unsatisfactory handover probably cause or contribute to Saul's death on 19 May 2019? NO (b) if NO or CANNOT SAY to Question 6(a), did that unsatisfactory handover possibly cause or contribute to Saul's death on 19 May 2019? YES

7. Did HMP Hewell deal with the handover about Saul from HMP Birmingham in a satisfactory way? NO

8. If NO to Question 7: (a) did the unsatisfactory way in which HMP Hewell dealt with the handover probably cause or contribute to Saul's death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 8(a), did the unsatisfactory way in which HMP Hewell dealt with the handover possibly cause or contribute to Saul's death on 19 May 2019?

9. Was the mental health referral made by healthcare at HMP Hewell 2019 adequate? NO

10. If NO to Question 9: (a) did the inadequate mental health referral at HMP Hewell probably cause or contribute to Saul's death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 10(a), did the inadequate mental health referral at HMP Hewell possibly cause or contribute to Saul's death on 19 May 2019?

11. Was information shared and considered adequately by healthcare staff at HMP Hewell? NO

12. If NO to Question 11: (a) did inadequate sharing and consideration of information by healthcare at HMP Hewell probably cause or contribute to Saul's death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 12(a), did inadequate sharing and consideration of information by healthcare at HMP Hewell possibly cause or contribute to Saul's death on 19 May 2019?

13. Was Saul's mental health adequately assessed and managed by healthcare at HMP Hewell? NO

14. If NO to Question 13: (a) did the failure by healthcare to adequately assess and manage Saul's mental health at HMP Hewell probably cause or contribute to his death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 14(a), did the failure by healthcare to adequately assess and manage Saul's mental health at HMP Hewell possibly cause or contribute to his death on 19 May 2019?

15. Should an ACCT mitigation plan have been initiated by prison staff at HMP Hewell? YES

16. If YES to Question 16: (a) did the failure by prison staff at HMP Hewell to open an ACCT probably cause or contribute to Saul's death on 19 May 2019? YES (b) if NO or CANNOT SAY to Question 16(a), did the failure by prison staff at HMP Hewell to open an ACCT possibly cause or contribute to Saul's death on 19 May 2019?
17. Was Saul Thomas' death contributed to by neglect? YES

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Report details

Reference: 2021-0423
Date of report: 21 December 2021
Coroner: David Reid
Coroner area: Worcestershire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Feb 2022 (estimated).

Sent to

HMP Birmingham

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.