Source · Prevention of Future Deaths

Geoffrey Hutton

Ref: 2021-0191 Date: 4 Jun 2021 Coroner: David Reid Area: Worcestershire Responses identified: 1 / 1 View PDF

HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient oversight of vulnerable prisoners and inadequate staff training.

Date 4 Jun 2021

56-day deadline 30 Jul 2021 est.

Responses identified 1 of 1

State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient oversight of vulnerable prisoners and inadequate staff training.

View full coroner's concerns

No social care referral had been made for Mr: Hutton, despite the need for one having been identified soon after his arrival at HMP Long Lartin: This was because no effective system for making such referrals to the relevant Local Authority appeared to be in place at the prison at the time of these events. The Safer Custody team were responsible for making such referrals, but members of that team suggested in evidence that they had insufficient time to deal with such issues_ The Safer Custody lead at the time of these events gave evidence as follows: (a) a social care referral; on the correct form as per the prison's Adult Safeguarding Policy. was never made; (b) such a referral should have been made within days of Mr. Hutton's arrival at the prison; (c) he was unable to explain why the system had broken down, but agreed that officers within his team had then, and continue to have insufficient time to devote to Equality & Disability issues; (d) there is still no training in place to ensure that officers are able to identify the need for a social care referral, and know how to make such a referral (2) There appears to be no effective system for allocating ACCT Case Managers at HMP Long Lartin. The officer ( Officer A ) who; when she opened the final ACCT document for Mr: Hutton, appointed herself as Case Manager for this ACCT, did so knowing that she would have no contact with him over the following two weeks. Officer A gave evidence that: (a) this was common practice at the prison; . (b) officers were discouraged from not naming a Case Manager when they opened an ACCT, even if as here ) it was opened at night; (c) she was hoping that another officer might "take it over" from her; As she predicted, she herself did indeed have no further contact with Mr. Hutton. Furthermore, this problem was not passed on or identified, and no other officer took over the Case Manager role_ Therefore there was no effective oversight of an ACCT involving a potentially very vulnerable individual: Of particular concern is that another officer appears to have filled in Officer A's details in the "name" and "signature" boxes at the foot of the ACCT Caremap, and dated them 7.2.19 ( the before Mr. Hutton's death thereby giving the impression that Officer A had reviewed and satisfied herself that the actions identified in the Caremap had been dealt with. In fact; the most important action on the Caremap, which required a social care referral, had not been completed: day

This lack of effective oversight was not confined to Mr. Hutton's final ACCT document: For his first ACCT document at HMP Long Lartin, only a month earlier; the named Case Manager had no involvement with it until the fourth ACCT Case Review, and made no entries on the Caremap which was signed off by a different officer ). heard evidence from a member of the current Senior Management Team at the prison that: (a) there is currently no formal training for the allocation of,or fulfilment of the duties of the ACCT Case Manager role; (b) this will be reviewed, and training will be organised. The lack of an effective ACCT Case Manager; who is able to provide proper oversight of an ACCT, is an issue which was raised by me in a previous Report to Prevent Future Deaths which followed the death of another prisoner at HMP Long Lartin David KIRSCH report dated 30.10.19 (3) Not all prison staff who out ACCT observations on vulnerable prisoners at night have received ACCT training: This issue became apparent when the Operational Support Grade member of staff

Responses

1 respondent

HM Prison and Probation Service Central Government

20 Sep 2021 PDF

Action Taken

HMP Long Lartin reviewed its adult safeguarding policy, is working on a memorandum of understanding with Worcestershire County Council, and is developing a directory of interventions for staff. They are implementing a new database for allocating ACCT Case Coordinators and making SASH training mandatory for OSGs. (AI summary)

View full response

Dear Mr Reid,

Thank you for your Regulation 28 report of 4 June 2021 following the inquest into the death of Geoffrey Harrison Hutton at HMP Long Lartin on 8 February 2019. I am informed there was an administrative error on our part for which I apologise and as such, I am grateful to you for granting an extension to the statutory deadline for my response.

I know that you will share a copy of this response with the family of Mr Hutton 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.

You have identified a number of concerns relating to social care referrals and the management of Assessment Care in Custody and Teamwork (ACCT) processes at the prison. Thank you for bringing these concerns to my attention.

Following the inquest, a review of the prison’s adult safeguarding policy was undertaken, and the prison is now working on a memorandum of understanding with Worcestershire County Council which will be completed by September 2021. The agreement sets out the strategic intent and joint commitment to improving the social care provision and procedures for those in custody.

The prison is also developing a directory to be used by staff in order to identify the most appropriate interventions for those in custody. This is due to be published later this month and will feature all interventions available through Worcestershire Social Care and will include information about the sensory impairment team within the local authority. A new template for referrals is more user friendly and takes less time to complete. Posters have been displayed around the prison to promote the new template and policy, and when the memorandum of understanding has been completed a notice to staff will be issued to inform all staff of the new processes.

The Safer Custody Team is responsible for managing social care referrals, and the weekly multi-disciplinary Safety Intervention Meeting (SIM) is attended by the local authority social care team, providing an opportunity to discuss any new referrals and assessments, and to

update on progress and discuss any actions to be taken. The healthcare provider, Practice Plus Group (PPG) has also signed up to the memorandum of understanding and joint working between healthcare, prison and social care teams will ensure that any outstanding referrals or actions are picked up and addressed and that sufficient time is given to discussing support options for prisoners identified as having additional needs.

Your second concern relates to the system for allocating ACCT case managers. You may be aware that HMPPS has introduced a revised version of ACCT which went live across the prison estate in July 2021; ACCT version 6. The changes are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person-centred approach which meets the needs of each individual. The term Case Manager has been replaced with Case Coordinator to reflect the fact that everyone involved in the ACCT process is responsible for ensuring that good quality support is provided. Specific training for ACCT Case Coordinators is being provided and staff must undertake the relevant modules before taking up the role. The Case Coordinator is responsible for coordinating and documenting multi-disciplinary case reviews, ensuring that support actions (previously the ‘Caremap’) are progressed and completed before the ACCT is closed, and for conducting the post-closure review.

At HMP Long Lartin a new database is being implemented to support the allocation of ACCT Case Coordinators. This contains information on staff rotas, periods of leave and how many open ACCTs each Case Coordinator currently has. This will facilitate effective allocation decisions and support a renewed focus on providing consistent and proper oversight and ownership of cases. In addition, the staffing resources within the safer custody team have been reviewed and an additional manager has been introduced, providing capacity to complete more assurance work around ACCT processes.

Your final concern relates to the fact that some Operational Support Grade (OSG) staff who carry out ACCT observations at night have not received ACCT training. We are making changes to the training provided to OSG staff, making it mandatory for OSGs to complete suicide and self-harm (SASH) training, which includes material on ACCT. Initial OSG training will also be changed, so that from early 2022 all new OSGs will receive the relevant SASH training modules as routine.

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.

Report sections

Investigation and inquest

On 20.2.19 an investigation was commenced into the death of Geoffrey Harrison HUTTON; prisoner at HMP Long Lartin; who died at the prison on 8.2.19, being 39 years of age. This investigation concluded at the end of the inquest on 27.5.21. medical cause of death was: 1a Hanging by ligature_ conclusion of the inquest was as follows: "Geoffrey Hutton died as the result of suicide. (a) HMP Belmarsh's failure to respond to HMP Long Lartin's email of 21.12.18, asking for a copy of their social care plan for Mr. Hutton, possibly caused or contributed to Mr: Hutton's death; (b) The Safer Custody team at HMP Long Lartin's failure to follow up that request with HMP Belmarsh possibly caused or contributed to Mr: Hutton's death; (c) HMP Long Lartin's failure to carry out a social care assessment or make a social care referral to the local authority probably caused or contributed to Mr Hutton's death; (d) HMP Long Lartin's failure to complete the Caremap action in Mr: Hutton's final ACCT document; which required a referral to social care by the Safer Custody team, probably caused or contributed to Mr: Hutton's death; (e) HMP Long Lartin's failure to provide adequate support to Mr: Hutton in relation to his hearing and communication needs, and make reasonable adjustments accordingly, probably caused or contributed to Mr. Hutton's death.

Circumstances of the death

Mr: Hutton hanged himself in his cell at HMP Long Lartin on 8.2.19, having made a ligature from the drawstring of a laundry bag: He had a significant hearing impairment; with cochlear implants in both ears; when those implants were not working he was profoundly deaf He also had recognized longstanding mental health and substance the The The misuse issues, in respect of which he was having regular contact with the Inclusion team in prison. At the time of his death, he was the subject of an ACCT document which had been open for some 2 weeks his second ACCT since his arrival at HMP Long Lartin on 19.12.18_ Mr: Hutton frequently expressed feelings of isolation and concern over his inability to have contact with his family and partner because of his hearing difficulties; and on several occasions self-harmed or threatened to self-harm because of the frustration he felt about this At the time of his death no social care referral had been made and therefore no social care plan was in place which identified and sought to meet his needs which resulted from his hearing issues_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action by conducting an investigation into the deficiencies and failures outlined above, and by conducting a review of the social care referral process and the ACCT process within your prison.

Inquest conclusion

"Geoffrey Hutton died as the result of suicide. (a) HMP Belmarsh's failure to respond to HMP Long Lartin's email of 21.12.18, asking for a copy of their social care plan for Mr. Hutton, possibly caused or contributed to Mr: Hutton's death; (b) The Safer Custody team at HMP Long Lartin's failure to follow up that request with HMP Belmarsh possibly caused or contributed to Mr: Hutton's death; (c) HMP Long Lartin's failure to carry out a social care assessment or make a social care referral to the local authority probably caused or contributed to Mr Hutton's death; (d) HMP Long Lartin's failure to complete the Caremap action in Mr: Hutton's final ACCT document; which required a referral to social care by the Safer Custody team, probably caused or contributed to Mr: Hutton's death; (e) HMP Long Lartin's failure to provide adequate support to Mr: Hutton in relation to his hearing and communication needs, and make reasonable adjustments accordingly, probably caused or contributed to Mr. Hutton's death.

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Report details

Reference: 2021-0191
Date of report: 4 June 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: 30 Jul 2021 (estimated).

Sent to

HMP Long Lartin

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.