Source · Prevention of Future Deaths

Jerome Jones

Ref: 2018-0369 Date: 1 Aug 2018 Coroner: Joanne Lees Area: Shropshire, Telford & Wrekin Responses identified: 2 / 3 View PDF

Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication of medical risks and drug workers' limited access to medical records, posed significant dangers.

Date 1 Aug 2018

56-day deadline 5 Jul 2019 est.

Responses identified 2 of 3

State Custody related deaths

Coroner's concerns

AI summary

View full coroner's concerns

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. (1)During the inquest evidence was heard that apart from some hourly checks by prison officers during the evening of the incident on 20/10/17 (the third known instance of NPS use by the deceased) no other specific checks were made on the deceased leading up to the date of his death .  This was a prisoner who had 3 known instances of NPS use within a relatively short space of time.  I heard evidence that the requirement for further checks would have had to come from the Healthcare team rather than from prison officers. I was told here is no policy or guidance to cover additional checks for a prisoner in a situation such as this.

(2)The inquest heard evidence from two Forward Trust Drug workers who although not medically qualified, considered that Mr Jones was at a ‘higher’ risk from NPS use due to using NPS with his existing congenital heart defect.  I was told there was no method of communicating this to either Healthcare or prison officers to enable further periodic checks to be undertaken particularly in light of the recent incident on 20/10/17.

(3)The two Forward Trust Drug workers were only aware of Mr Jones existing heart condition because he disclosed this to them himself. This enabled them specifically to tailor their advice to cover the impact of Mr Jones continued NPS use on his heart.   Forward Trust do not appear to have access to prisoner medical records for reasons of patient confidentiality and there does not appear to be any alternative way of ensuring they have all the information about a prisoner in order to help them with their drug use.

Responses

2 respondents

Shropshire Community Health NHS Trust NHS / Health Body

31 Aug 2018 PDF

Noted

The trust describes current practices for observing prisoners using illegal substances and referring them to support services. It notes that Forward Trust's access to medical records is under discussion with NHS England. (AI summary)

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Dear Mrs Lees RE JEROME JASON OMRI JONES Subject to your Regulation 28 Report below is the response for Shropshire Community Health NHS Trust in relation to your concerns
1) Observations following repeated use of NPS Current practice is that following a prisoner using any illegal substance nursing staff will instruct prisoner officers to conduct additional observations for a short period of time to ensure the prisoners has fully medically recovered from the effects of the substance. They are also instructed to contact healthcare staff if there any concerns. This is part of HMP/YOI Stoke Heath joint strategy document for the management of NPS. Repeated use will trigger referral to Forward Trust staff to engage with the prisoner to motivate them to modify their drug taking habits. Whilst there is no separate guidelines for long term increased observation of a prisoner engaging in drug risk related behaviour, there is an overall policy and safeguarding mechanism for prisoners at risk of harm to themselves (the ACCT process). Any member of staff within the prison can instigate the safeguarding process if they feel this is appropriate. This is likely to increase observation but will not prevent the prisoner from engaging in risk taking behaviour.
2) Communicating congenital heart defect. Healthcare staff were aware of his condition. The Forward Trust can be given access to medical records, they are in discussion with NHS England, the commissioner of the service, to action this. As with any other prisoner arriving at HMP/YOI Stoke Health, Mr Jones would have been asked at reception as part of disability information sharing if he had any conditions that he would like to share with the prison authorities. This form would have been sent to the disability liaison officer at the prison. As with any other Trust patient we would not share medical information without the patient or patient representative consent. Corporate Affairs William Farr House Shrewsbury Shropshire SY3 8XL Telephone: 01743 277 661 Fax: 01743 277 663 Website: www.shropscommunityhealth.nhs.uk

Mike Ridley –Chairman Julia Bridgewater – Chief Executive
3) Access to medical records As stated in (2) the Forward Trust is addressing this with the service commissioners, NHS England. The receipt of this notice has emphasised the value of healthcare staff attending these and similar inquests, even though there may not be any identified issues to address. We will ensure attendance in the future.

HM Prison Probation Service Central Government

4 Oct 2018 PDF

Action Taken

An updated drug strategy has been launched at the establishment, and staff were reminded of communication protocols for prisoners at risk from repeated use of psychoactive substances. By April 2019, Forward Trust will have access to SystmOne to improve communication with prison and healthcare staff. (AI summary)

View full response

Dear Mrs Lees,

Inquest into the death of Jerome Jones

Thank you for your Regulation 28 Report of 1 August addressed to the Governor of HMP/YOI Stoke Heath, the Shropshire Community Health NHS Trust and the Forward Trust following the conclusion of the inquest into the death of Jerome Jones. As Chief Executive Officer I am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS). Thank you for allowing me additional time in which to do so.

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

I am grateful to you for bringing your concerns to my attention. I am aware that the Shropshire Community NHS Trust wrote to you on 31 August. In addition to the information in their response, an updated drug strategy has been launched at the

establishment. All staff were notified of this last month by way of a Notice to Staff which also reminded them that healthcare staff are responsible for determining when additional checks of prisoners at risk from repeated use of psychoactive substances are necessary, and that this must be communicated by them to all prison discipline staff.

In September, a staff notice was also issued by the Governor to all Forward Trust Drug workers at the establishment to remind them of how to share information with prison and healthcare staff. To further improve communication between Forward Trust drug workers and healthcare staff, every member of Forward Trust will be given access to SystmOne by April 2019, in order that they can both enter information onto the system and access it.

Thank you again for bringing these matters of concern to my attention. Please be assured that learning from the circumstances of Jerome Jones’ tragic death will be shared more widely with colleagues across the prison estate.

Report sections

Investigation and inquest

On the 30th October 2017 I commenced an investigation into the death of Jerome Jason Omri JONES, 26 years of age. The investigation concluded at the end of the inquest on the 18th to the 20th July 2018. The conclusion of the Jury in the Record of Inquest (ROI) was a narrative conclusion recorded in Box 4 as: The deceased passed away due to a combination of an underlying heart condition and the effects of a synthetic cannabinoid on his heart.

Recorded in Box 3 of the ROI the jury found that ‘proactive steps were taken to safeguard Mr Jones prior to the incident but these were ultimately insufficient’.

Circumstances of the death

The deceased was a serving prisoner at the time of his death in HMP Stoke Heath. He had been transferred there in July 2017. He had a pre existing congenital heart defect and was a known user of New Psychoactive Substances (NPS). He died on 27/10/17 in the Princess Royal Hospital, Telford. Earlier that evening he had been found unresponsive in his cell having been suspected of using NPS. A post mortem revealed the cause of death as 1a) Sudden cardiac death 1b) congenital heart disease with fibrosis of the left ventricle and toxic effect on myocardium. Toxicology found a synthetic cannabinoid known as 5F‐ADB in his blood. Between his arrival at Stoke Heath and his subsequent death on 27/10/17, Mr Jones had at least 3 known instances of NPS use the most recent on which was only a week before his death where he received emergency treatment although he was not admitted to hospital. A week later, he was again found unresponsive in his cell and was determined by paramedics to be in cardiac arrest. Despite concerted efforts to save his life by prison staff and paramedics he remained in PEA and was later sadly pronounced dead at 21.10 pm at the Princess Royal Hospital. The inquest focused on the following central issues;

● The events leading up to the discovery of Mr Jones in his cell on 27/10/17; ● The measures taken by HMP Stoke Heath to manage both his heart condition and his known use of NPS with particular reference to the incident on 20/10/17; ● The measures taken by HMP Stoke Heath to Mr Jones mental health in so far as it related to his drug use; ● How Mr Jones was able to access NPS and what policies and procedures were in place at H M Prison, Stoke Heath to prevent this? ● If there was any delay in calling an ambulance to Mr Jones, the impact of any delay if it is possible to say.

Copies sent to

I am also under a duty to send the Chief Coroner a copy of your response1st August 2018

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Shared signals

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Report details

Reference: 2018-0369
Date of report: 1 August 2018
Coroner: Joanne Lees
Coroner area: Shropshire, Telford & Wrekin

Responses identified

Responses identified 2 of 3

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 Jul 2019 (estimated).

Sent to

Forward Trust

HMP Stoke

Shropshire Community Health NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.