Source · Prevention of Future Deaths

Tomasz Nowasad

Ref: 2019-0445 Date: 20 Dec 2019 Coroner: Nigel Meadows Area: Manchester (City) Responses identified: 2 / 2 View PDF

There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.

Date 20 Dec 2019

56-day deadline 4 Mar 2020 est.

Responses identified 2 of 2

State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

The below specific Issues of concern could have wider application throughout the whole prison estate rather than simply being regarded as local to Manchester prison 5 1 The context of this case has to be seen In the light of the fact that In 2019 two self-inflicted deaths happened at HMP Manchester There were four In 2018 and my records Indicate that there have been 29 from the beginning of 2006 up to date In view of the evidential Issues highlighted above It IS suggested that there has been a repeated theme In the majority of these cases that there was an over reliance and emphasis on the assertions made by a prisoner that they "had no thoughts of self-harm or suicide" This is often simply recorded in ACCT reviews by ticking boxes on the review document. Whilst it Is appropriate for this Issue to be addressed whenever a prison IS on an ACCT either by healthcare staff or at ACCT reviews because In many cases prisoners still go on to harm themselves or commit sulcide It should not be regarded as definitive This was recognised and recorded In the latest PPO Investigation Report relating to a death that occurred on 5 April 2019 This was specifically referred to In paragraph 26 of the report which sald "In previous investigation Into self-inflicted deaths at Manchester; we Identified weaknesses In the risk assessment of prisoners at risk of suicide and self-harm We found In particular that staff placed too much emphasis on prisoners presentation and did not give sufficient consideration to their risk factors 5 2 PSI-64/2011 recognises that there are a number of potential triggers to self-harming behaviour or sulcide All staff should be alert to the Increased risk of self-harm or his suicide posed by prisoners with these risk factors and should act appropriately to address any concerns, Including opening an ACCT If necessary However_ It IS suggested that the list of factors Is not exhaustive and everything neds to be considered In light of the overall picture This will usually Involve discipline staff and health care staff It Is suggested that thereafter, particularly If the prisoner is moved to the HCC, considering all the risk factors and the changing position taking Into account the previous recorded history of the prisoner from both a health care and general prison service records_ This IS especially so when ACCTs are reviewed and a prisoner Is being discharged from the ACCT or moved out of the limited number of safer cells avallable In the prison There has to be consideration of the overall or 'blg picture' with regards to the risks that the prisoner poses 5 3 It is suggested that whenever an assessment of risk of self-harm or suicide is undertaken there IS a written record made of the factors or Issues Involved In this or what weight or consideration was given to them and how the risk assessment was arrived at It IS suggested that It would be appropriate for GMMH and HMPS to ensure that this IS introduced 5 4 It appears that there was no consistent use of the language line interpretation service by HMPS or GMMH staff; and It is suggested that wherever an Identified need for the use of this service IS recognised It should be used on all healthcare interviews as well as at ACCT reviews While some prisoners may speak some, little or virtually no English, It is essential that every effort IS made to ensure that they can understand, so far as It possible, the Issues being raised and discussed with them_ 5 5 It IS suggested that there was an absence of timely, full and accurate clinical record keeping by members of GMMH healthcare staff (whether be healthcare assistants, nurses or doctors) This IS a professional requirement under GMC Good Practice and the NMC code of conduct It IS suggested that steps are taken to ensure this IS completed in all cases and appropriate audits undertaken to check on this. 5 6 It Is suggested that whenever there IS a healthcare Interaction with a patient prisoner and more than one healthcare member of staff IS present, their identities should be recorded and all clinically relevant information is Included within the System One records and checked between those present as full and complete 5 7 It Is suggested that whenever there is a healthcare interview and member of prison discipline staff Is present, records should be kept by GMMH and HMPS of who was there, but also HMPS staff should record separately within their records evidence and Information relevant to the risk of self-harm or suicide 5 8 It IS suggested that whenever there IS a decision made to move a prisoner who IS subject to an ACCT from the HCC to another location In the prison; prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant Information IS handed over to colleagues 5 9 It Is suggested that receiving HMPS staff should ensure that read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and sulcide and how It has been managed to date and whether or not that needs to be reviewed on arrival concerns should be escalated 5 10 It IS suggested that GMMH and HMPS staff should ensure as Is far as IS reasonably possible_that the patlent_prisoner_has a real understanding and comprehension of the_ being they being history they Any reasons for transfer and a regime to which they are going, particularly If they have been moved from the HCC when occupied a safer cell but were going to an ordinary cell with a number of ligature points The staff themselves have to have a clear understanding of the reasons for transfer and what the new wing regime or locations means for the prisoner and whether or not It Is appropriate Records should be kept of the reasoning and justification 5 11 It Is suggested that there should be an auditable process of ensuring that all appropriate Information Is handed over between different shifts of GMMH and HMPS staff so that there IS a continuity and consistency of available Information 5 12 It IS suggested that GMMH staff should ensure that when they have any clinical interactions with patient prisoners they familiarise themselves with all the developing relevant medical history including recent events and record what have reviewed or considered 5 13 It IS suggested that since that the overwhelming majority of prisoners who kill themselves do so by lgatures particular care should be taken when prisoner who is on an ACCT Is moved from a safer cell to an ordinary cell and their ACCT should be carefully reviewed and the number type and frequency of observations Prisoner can quickly get used to the regularity of observations and undertake self-harming or suicidal behaviour when they think will not be seen or have contact from HMPS or GMMH staff 5.14 It is suggested that HMPS should consider increasing the number of Safer cells throughout the whole of the prison and also having more CCTV monitored cells_ 5 15 It is suggested that it I8 not appropriate for GMMH clinical or Nursing Staff to put the onus or responsibility on a prisoner to interact with HMPS staff to try and understand why may be moving from one location to another without both being present and the language line service used to try and ensure no miscommunication and that appropriate written guidance should be given to all staff 5 16 It IS suggested that It Is not appropriate to indicate to a patlent prisoner that they are not sO Ill or vulnerable as others In considering a move out of the HCC because that may Influence their cooperation and disclosure of their symptoms and presentation It Is suggested that guidance IS Issued to GMMH staff about this

Responses

2 respondents

NHS England NHS / Health Body

20 Dec 2019 PDF

Action Taken

NHS England published guidelines and supporting documents for Health and Justice Clinical Reviewers in Sept 2018 and has published an amended specification for the provision of mental health services in prison. Additional resources were provided to HMP Manchester for mental health staffing. (AI summary)

View full response

Dear Mr Meadows

Re: Letter of Concern written under Paragraph 37 of the Chief Coroners Guidance number 5 on Prevention of Future Deaths – Mr Tomasz NOWOSAD, Date of Death 2 February 2017.

Thank you for your letter dated 20 December 2019 (hereinafter the ‘letter’) concerning the death of Tomasz Nowosad on 2 February 2017. At the very outset I would like to express my deep condolences to Mr Nowosad’s family.

Following the conclusion of the inquest you raised concerns regarding the skills and knowledge of the Clinical Reviewer whose report was used as part of the evidence provided to the inquest.

Your letter mentions that you are aware of the NHS England Guideline for Health and Justice Clinical Reviewers1, published on 21 September 2018. Alongside this document, NHS England also published a suite of supporting documents and templates for Clinical Reviewers and commissioners. These can be found at:

reviewer/

In addition to the above guidelines NHS England also published, on 21 September 2018, Guidelines for the provision of Clinical Reviewers to support Health and Justice deaths in custody investigations2. On 12 June 2017 Deputy Prison and Probation Ombudsman and National Clinical Quality Lead for Health and Justice at NHS England, met with you in order to inform and shape the development of these guidelines. NHS England has sought to implement and develop a robust framework based upon your comments and feedback arising from that meeting. It is deeply regretted that the sad circumstances of this case have prompted further concerns. I hope that the

1 https://www.england.nhs.uk/wp-content/uploads/2018/10/guidelines-for-health-and-justice-clinical- reviewer.pdf 2 https://www.england.nhs.uk/wp-content/uploads/2018/10/guidelines-for-the-provision-of-clinical- reviewers-to-support-health-justice-deaths-in-custody-investigations.pdf

Mr Nigel Meadows HM Senior Coroner HM Coroner’s Office Manchester City Area The Exchange Floor The Royal Exchange Building Cross Street Manchester M2 7EF

Professor Stephen Powis National Medical Director Skipton House 80 London Road SE1 6LH

6th March 2020

NHS England and NHS Improvement following information will help to assuage those further concerns in relation to Clinical Reviewers and Clinical Reviews.

After considering feedback relating to the provision of clinical reviews across the North region NHS England resolved to procure a more robust and secure contractual arrangement in order to address concerns and act upon that feedback. A revised procurement exercise for the Death in Custody Clinical Review service across the North of England was undertaken during 2018/19 with a contract start date of April 1st 2019. The procurement included the incorporation of the newly approved guidance from NHSE (the links of which are provided on the previous page and in ‘1’ and ‘2’) into the service specification, including sections regarding compliance with governance and quality aspects of service delivery along with confirmation of appropriate payments. Robust processes around quality assurance, approval pathways and relevant performance monitoring were included in the contract and compliance with the guidance was mandated. The compliance is monitored through the quarterly contract performance meeting, against the clinical service provider data in the quality schedule return (see template in Annex 1).

As part of the new arrangements NHSEI Health and Justice Quality Leads are required to approve the identification and selection of appropriately skilled and suitable individuals by the service provider. This involves ensuring the clinical reviewer has the appropriate skill set through review of qualifications. There is a recognition that there may be gaps in knowledge, in some instances, however these are mitigated by the clinical reviewer accessing support from other professional advisors and subject matter experts as required. All appointments must be agreed by NHSEI and an up to date register is kept of all reviewer’s professional registration, either as a nurse or doctor. In addition data regarding qualifications and training and evidence of ongoing mentorship and supervision by experienced professionals, within the service is also documented. Reviewers are assessed for their suitability to carry out specific reviews through discussion between the service provider and NHSEI. For example, only reviewers who have experience within mental health services will be considered suitable for reviews with a mental health component and likewise with physical health. The final draft clinical review produced after each investigation must now be quality checked and approved by NHSEI Health and Justice Quality Leads before being passed to the Prison and Probation Ombudsman for their approval. It is explicit in the contract for the service and in the guidance that clinical reviewers should not be expected to act as an expert witness but are expected only to review the service provided to the deceased and map against the service they could have expected to receive in the community.

Contract meetings are held quarterly between the commissioner of the services, the quality leads from the North West, Yorkshire and Humber, and Cumbria and the North East regions, and provider representatives from the service. There is a performance and quality data set for the service which is provided at the meeting and for which the service is held accountable (See Annex 1). Current progress with this contract demonstrates good practice in maintaining an accurate record of professional registration and qualifications, clinical reviewer supervision and appraisal. There are some process issues with some clinical reviews regarding a range of reasons e.g. access to information and clinical records, some of which are outside of the providers control. All processes throughout the period of an

NHS England and NHS Improvement investigation are jointly agreed between NHSEI, the service provider and the PPO and any issues or problems are dealt with in the contract meetings with action plans for service improvement being formulated.

It is hoped that such additions to the procurement and oversight of Clinical Reviews will ensure the robustness of future Clinical Reviews.

In relation to the review concerning Mr Nowosad, I recognise the concerns you have outlined in your letter.

NHSE were informed of the tragic death of Mr Nowosad on 3rd February 2017 by Health Care Provider Staff. NHSE were contacted on 23rd March 2017 to inform them that there would be a delay to the publication of the first draft of the clinical review due to delays in the reviewer interviewing staff. The PPO therefore granted an extension. The first draft of the clinical review was sent to NHSE on 10th April 2017, which was quality checked by NHSE. The Quality lead made a range of comments on the report and a revised version was produced on 5th May 2017. The comments were largely asking for further clarification regarding observations made by the clinical reviewer such as why a particular action wasn’t followed up and the reason why certain actions had not been undertaken in Mr Nowosad’s care. There were two references made to use of outdated guidance suggesting the reviewer re look at the more recent guidance.

On 14th July 2017 the first draft of the PPO report was submitted for factual accuracy checking by the prison and health services. On 19th July 2017 concerns were raised by consultant forensic psychiatrist, regarding potential “misinterpretation” of comments which he had made and which he felt may not have been fairly reflected in the report. Further suggested factual accuracy changes were submitted to NHSE by the prison health provider, along with an action plan to address recommendations made in the report. These suggested changes were submitted by the NHSE quality lead on 24th July 2017 for comment by the clinical reviewer and PPO. The clinical reviewer responded to these suggestions on 25th July 2017 by stating that, over the course of several email discussions with they had reached an understanding of the position. The reviewer acknowledged that the purpose of the report was to identify opportunities to learn lessons. She felt, however, that good mental health care was provided to Mr Nowosad. The final report was published by the PPO in October 2017 after additional suggested changes to the report were received from the prison service.

Since the very sad death of Mr Nowosad in 2017, and in recognition of the scope for improvement that had been identified, NHSE has published an amended specification for the provision of mental health services in prison (see Annex 2) and all providers must comply with the scope of the specification. HMP Manchester audited its services against the requirements of the specification and, as a result, additional resource was provided by NHSE to enhance the service accordingly. This resulted in additional investment into HMP Manchester which provided for additional mental health, nursing, psychology and well-being staff.

NHS England and NHS Improvement Additionally, I am aware that HMPPS are currently rolling out revisions and amendments to the ACCT process which will include enhancements to the multi- disciplinary contribution of the clinical team within the prison.

I trust that the steps outlined above relating to the framework for clinical reviews and reviewers will reassure you that NHS England has taken steps to ensure the robustness of such reviews in the future.

I am deeply saddened by Mr Nowosad’s death and the fact that you have identified concerns in the area of clinical reviews. I am however grateful for the opportunity to highlight in this letter the work that has been carried out to ensure that such concerns do not arise in the future.

HM Prison and Probation Service Central Government

6 Mar 2020 PDF

Action Planned

HM Prison and Probation Service are rolling out improvements to the ACCT process and are increasing the numbers of safer cells available to governors, including at HMP Manchester. (AI summary)

View full response

Dear Mr Meadows

Thank you for your Regulation 28 Report of 20 December 2019 following the inquest into the death of Tomasz Nowosad at HMP Manchester on 2 February 2017, and for allowing a small extension to the statutory deadline for my reply.

I am grateful to you for bringing to my attention a number of matters of concern, many of which are relevant across the prison estate. I have consulted with the Governor of HMP Manchester and, where relevant, will mention action that has been taken locally at the prison as well as work that is taking place at national level. I understand that the healthcare provider is responding separately to your concerns about clinical issues.

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

Before turning to your concerns, I would like to clarify the position with regard to the number of self-inflicted deaths at HMP Manchester in recent years. At 5.1 you correctly point out that there were two such deaths in 2019, and four in 2018. However, it is not the case that there have been 29 such deaths since 2016. The correct figure for the period 2016-2019 is 11 self-inflicted deaths.

A number of your concerns relate to the Assessment, Care in Custody and Teamwork (ACCT) case management process for those identified as being at risk of self-harm or suicide. We have been working hard to improve the way that this system operates. Following a comprehensive review, we have devised a new version of the form and associated guidance, and I am pleased to note that much of what you have suggested has been adopted as part of that. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was piloted in ten establishments in 2019 and the feedback has been positive. We are currently making some further changes before rolling it out across the prison estate later in 2020. I am confident that this will address the concerns that you have raised and bring further improvements to the work that staff do to keep prisoners safe.

I would like to comment more specifically on four issues that are at the heart of the concerns that you have raised.

First, risk assessment (5.1-5.3). You have described an over-reliance on a prisoner’s presentation and what they say, rather than a consideration of all risk factors, and drawn attention to the fact that this has also been identified by the Prisons and Probation Ombudsman in relation to other self-inflicted deaths at the prison. You have explained the need for a holistic approach to risk assessment, and for decisions to be made in a defensible way, and recorded appropriately. These are issues that have been at the centre of our thinking as we have redesigned the ACCT guidance, which will be much clearer about the risks, triggers and protective factors that staff should be seeking to identify, and the ACCT form itself, which will provide prompts to look for other factors that may be relevant as well as space for staff to record the reasons for decision. The associated training packages are currently being redeveloped and will be delivered to all new staff through POELT training and made available as refresher training for existing staff. A specific session on the risks and triggers for self-harm and suicide will form a major part of this training.

Second, interpretation services (5.4). You express concern about inconsistent use of such services by staff. A national contract with The Big Word ensures the availability of interpretation services across the prison estate. The new ACCT guidance will emphasise the importance of their use throughout the process, and the new ACCT form will include prompts to consider the use of the service at every significant point, including assessments and case reviews. In advance of the roll out of the new version of ACCT, the Governor of HMP Manchester has taken action to improve the use of the service at the prison, for example by making conference style telephones available for use at case reviews.

Third, the movement of a prisoner subject to ACCT to a new location, particularly where this involves discharge from a specialist location such as inpatient healthcare (5.7-5.11). Your concern here is that information should be passed between locations, and particularly that staff at the receiving location - and the prisoner themselves - should be clear about the reasons for the move. Again, the new ACCT form will assist with this, providing a specific template for use at case reviews that occur in specialist locations, including healthcare centres and segregation units. Where a decision to discharge is the result, it provides a prompt to share relevant information with the receiving location (from which a member of staff must attend the review). The new ACCT guidance is much clearer about the need to involve the prisoner in all decisions that are taken, including those concerning location. In advance of implementing the new system, it is now the practice at HMP Manchester for a case review to be held prior to any location move, including moves from healthcare to residential wings. These reviews are attended by a representative from the new location, providing an opportunity to discuss any concerns and issues relating to risk, including how a change to location and regime might affect risk. Notes of the review and any decisions made are recorded in both the ACCT document and in the NOMIS case notes. Where an enhanced assessment has been completed by the psychology department, this is also forwarded to the new location.

Fourth, safer cells (5.13-5.14). You are concerned that more such cells should be available, and that the movement of prisoners who are subject to ACCT from a safer cell to another location should be carefully managed. I understand the importance of reducing access to the means of suicide wherever possible. Physical safety, including increasing the provision of accommodation free of ligature points, is one of the work streams in our national prison safety programme. You will appreciate that large amounts of capital investment are necessary to improve the environment in this way, and we are not able to move as swiftly as we would want to. However, wherever possible we are increasing the numbers of safer

cells available to governors. At HMP Manchester there are currently fourteen safer cells. Ten are in the healthcare unit, five of which are equipped with CCTV. Four non-CCTV cells around the prison have electro-chromatic doors. Whilst there are currently no plans to increase the number of safer cells, we will keep this under review.

Whilst safer cells are an important part of our strategy for managing acute risk of suicide, they are not a long-term solution in terms of care for individuals. The multi-disciplinary engagement and support that is provided through ACCT is designed to manage and mitigate risk by identifying and meeting individual needs. In most cases this can be done without the removal of ligature points or observation through CCTV. As explained above, the new ACCT form and guidance are clear that all changes of location, including moves out of safer cells, require careful management.

Thank you again for bringing these matters of concern to my attention. I hope that this response has provided reassurance that those that are for HMPPS are being addressed, at national level through the roll out of improvements to ACCT and, wherever possible, locally at HMP Manchester in advance of this.

Report sections

Investigation and inquest

concluded the inquest into the death of Tomasz Nowasad on the 12th December 2019 and the jury recorded that died from-Ia Hanging The came to the Conclusion Suicide Contributed to by Neglect

Circumstances of the death

The deceased was born on 16 March 1989 and was found dead In his cell A34 on A wing at HMP Manchester on 2 February 2017 at about 20 pm as a result of him hanging by a ligature attached to the window about 27 hours after arriving on the wing at about 4 20 PM on February having been transferred from the healthcare centre (HCC) This was an ordinary wing location and In a "non-safer" cell with a number of potential ligature points His death was reported to the police and to the Coroner and an investigation Into his death Immediately commenced The PPO also commenced an Investigation and appointed an investigator and the NHS appointed a clinical reviewer It appears that the clinical review report was completed on 10 April 2017 and the Initial PPO report was published on 14 July 2017 The clinical reviewer was registered nurse and health visitor and Is a registrant panellist with the NMC The clinical reviewer says that "for the last eight years have inspected health services which will care In places of detention Including_prisons with a focus on primary care Bury Org Jury services, mental health services and substance misuse services have previously completed 6 clinical reviews for NHS England and the PPO The clinical reviewer was not a registered mental health nurse, a GP or a Psychiatrist and does not appear to have any experience of working In healthcare services as a practitioner in a category A high security prison The_Clinical Revlew Report The terms of Reference are Identified at Paragraph 1 01 and 1 04 identifies what are described as questions and at 1.04 says "the review will; examine the provision of clinical care and treatment, including both risk assessment and risk management Identify any care or service delivery failings along with the factors that contributed to these problems Identify any route cause(s) that Inform the identification of learning opportunities ,make timely clear and sustainable recommendation prison healthcare provider and service provide explanations and insight for the relatives of the deceased" The copy of the system 1 records provided to the court amounted to 81 pages and that was within the jury bundle during the Inquest The jury also had a complete copy of the ACCT and other relevant documentary evidence The Review report IS a total of 51 pages and has a chronology as appendix 2 of the review report It appears at face value to be a copy of the original System records comprising paginated between 28and 51 However, the related to 16 January appears on pages 45 and 46 Is headed "scanned from Mersey care NHS notes of Dr C" The 23rd January note Is similarly referred to and included on page 48 The last interview on 30 January IS once again similarly referred to and appears starting on page 49 These entries replicate word for word typed notes of the Interviews that were obtained during the inquest but had not been seen by the court before but there IS no Indication whatsoever as to how these entries came to be added to the system one records or when and why the typed notes on Mersey Care NHS notepaper were not simply scanned in It would seem on the face of it that the contents have been removed from that those notes and scanned In separately It is apparent that the reviewer was unaware or even understood the correct position and when, If at all; the healthcare staff could have had access to the full notes and considered them The reviewer needed to be absolutely clear as to when were actually uploaded onto the system and how they appear on the system records which may be different from how appear In appendix 2 of the reviewers report In addition exactly when were there were uploaded, how and by whom? Why do seem to appear In the format in appendix 2? The reviewer had to look at both a physical healthcare and mental health care It IS also said that the deceased was admitted" to hospital under section 2 of the MHA between 20/1/16 and 25/1/16 and again between the6/4/16 and the 6/8/16 The first of those dates is correct but the second Is incorrect The correct date for the next admission IS between 5/4/16 and 2/5/16 He was then "detained" under section 3 of the MHA between 3/5/16 and 2/6/16 The statutory criteria for those admissions are different All of these are compulsory admissions and not voluntary GMMH were the responsible NHS Trust for the community admissions and are also the responsible health provider for their physical and mental health when a prisoner IS In custody at HMP Manchester Key entry they they they they they

The conclusions of the clnical revlew The reviewers' conclusions are recorded in section 7 of the report In particular paragraphs are relevant 7 02 Having reviewed the physical and mental health clinical care extended to Mr Nowosad, consider that the majority of care received was of a reasonable standard and was largely equivalent to and perhaps In some Instances, particularly In relation to some aspects of the mental health care , better than that which he would have received in the wider community 7 06 In relation to the timing of his transfer from the healthcare unit to the main prison; Mr Nowosad had indicated on several occasions while he was on the healthcare unit; that he felt safer there and that he was frightened about how he would feel if he was moved back to prison wing: The final decision to move him appears to have been made at least partly on the basis of him asking for this move, yet none of the records describe this request There did not appear to be any particular pressure to free up spaces on the healthcare unit at that time 7 07 Steps were taken to make Mr Nowosad's transition from the unit into the main prison as safe as possible Including an ACCT review and a risk assessment before he was moved He remained on an ACCT with checks made at intervals during the day and the night and he was to have a 72 hour period of assessment on A wing However In the light of his consistently expressed fears regarding how he might feel on a main wing, It appears more might have been done to better identify the source of his specific fears and whether his mental state was as stable as it appeared In the light of his expressed fears, it might have been prudent to keep him on the unit until he indicated that the fears had receded However, acknowledge, that even had his move to the main prison been postponed a little longer, sadly he may still have decided to end hIS own albeit at a later point summary of themain or_slgnificant evidence admitted and heard at the_ nquest and the Lry's conclusion The deceased had an established dlagnosis of schizophrenia which required three compulsory detentions Mental Health Act

Action should be taken

In my opinion action should be taken to prevent future deaths and belleve you and your organisation have the power to take such action

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Report details

Reference: 2019-0445
Date of report: 20 December 2019
Coroner: Nigel Meadows
Coroner area: Manchester (City)

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: 4 Mar 2020 (estimated).

Sent to

Greater Manchester Mental Health NHS Foundation Trust

HM Prison and Probation Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.