Source · Prevention of Future Deaths

Timothy Shaw

Ref: 2018-0047 Date: 15 Feb 2018 Coroner: Caroline Beasley-Murray Area: Essex Responses identified: 1 / 5 View PDF

Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was also substandard.

Date 15 Feb 2018

56-day deadline 3 Apr 2018

Responses identified 1 of 5

State Custody related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Continued……………………..  Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place.  The processes and systems for reducing access to illegal substances need to be improved and tightened up  The processes for referrals by both prisoners and staff to psychosocial services needs to be tightened up and improved.  The standard and accuracy of record keeping by both disciplinary and Healthcare staff needs to be improved.

Responses

1 respondent

Care UK Private Sector

27 Feb 2018 PDF

Noted

Care UK acknowledges receipt of the report but states they ceased providing healthcare at HMP Chelmsford on 26 May 2017 and therefore will not be filing a substantive response. (AI summary)

View full response

Dear Madam

The inquest touching the death of Timothy Shaw Deceased HMP Chelmsford Date of death: 2 March 2017

I acknowledge receipt of your Regulation 28 Report dated 15 February 2018 to which a response is due by 3 April 2018.

As you are aware, Care UK ceased to be the providers of healthcare at HMP Chelmsford on 26 May 2017.

I have been passed the emails from Marianne Robson dated 23 February 2018 where she has advised that the PFD report was forwarded to Care UK for information purposes only and that you do not expect a response from Care UK. Accordingly we are not filing a substantive response. However, if you require any further assistance, please do not hesitate to contact me.

Report sections

Investigation and inquest

On 20 March 2017 I commenced an investigation into the death of Timothy John Shaw. The investigation concluded at the end of the inquest on 30 January 2018. The conclusion of the inquest was:-

Accidental death. The jury believe that with more resources and better communication further steps could possibly have been taken to manage Mr Shaw’s risk of dying and may have prevented his death.

Circumstances of the death

Timothy Shaw, who was 34 years old at the time of his death, had a long history of offending and substance abuse. On 9 January 2017 he was remanded in custody to HM Prison Chelmsford. On 30 June 2017 he was sentenced to a 6 year imprisonment. During his time in custody he was subject to three ACCT processes. It would appear that during his time in prison, he was using drugs including prescription medication and morphine patches. On 19 February, he was found under the influence and on the morning of 28 February, he was found collapsed in his cell. He was taken to Broomfield Hospital and he died there on 2 March 2017. It would appear that no referral to the mental health service was made.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2018-0047
Date of report: 15 February 2018
Coroner: Caroline Beasley-Murray
Coroner area: Essex

Responses identified

Responses identified 1 of 5

4 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Apr 2018.

Sent to

Care UK Clinical Services

Essex Partnership University NHS Foundation Trust

Farleys Solicitors LLP

HM Prison and Probation Service

Phoenix Futures

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.