John Chapman

Dear Mr Rheinberg,

Thank you for your Regulation 28 Report of 29 November 2017 following the inquest into the death of Christopher Talbot at HMP Preston on 28 November 2014. You have addressed the report to the Governor and to Ministers, and I am responding because the matters of concern that you have raised are all within my area of responsibility. I am grateful to you for bringing them to my attention.

I know that you will share a copy of this response with Mr Talbot’s family and I would like first 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.

Reception officer training You have drawn attention to the importance of ensuring that training for reception officers includes their having access to PSI 07/2015 Early Days in Custody – Reception, First Night in Custody, and Induction to Custody.

Every member of staff in reception at HMP Preston has been provided with a copy of the PSI and set an objective to read and comply with it in their Staff Performance and Development Record. Line managers will monitor the achievement of this objective. Copies of the PSI are also available in the reception area.

You may also wish to be aware that we have introduced revised suicide and self- harm prevention training for all staff in HMPPS, and that at Preston staff working in reception are being given priority as this is rolled out.

Resuscitation aids Your next concern is that not all staff at Preston carry resuscitation aids. Emergency boxes containing resuscitation aids are currently available on all residential units at the Prison, and there are plans for all staff with prisoner contact to be issued with them by June this year.

Sharing learning from deaths in custody Your third concern is that staff at HMP Preston are not notified about the manner of each non-natural death that occurs. The establishment’s contingency plans have been amended to instruct managers to provide relevant information to all staff in the event of future deaths at the prison.

We are committed to sharing learning from the circumstances of deaths as widely as possible across the estate; indeed, we frequently issue national learning bulletins to raise staff awareness of risks identified from them.

National instructions on procedures at night Finally, you suggest that an instruction issued at HMP Preston about procedures at night could be issued nationally. We have reviewed the content of this local instruction, and found that it has been drawn from existing national policies, including PSI 64/2011 Safer Custody, PSI 24/2011 Management and Security of Nights and PSI 63/2011 Management of the Local Security Strategy. As a result I am satisfied that no further action is necessary, as the relevant instructions are already in place across the estate.

Thank you again for bringing these matters of concern to my attention.

Dear Mr Rheinberg,

Thank you for your Regulation 28 report dated 11th January 2018. I note the concern expressed in your report that information relevant to an assessment of Mr Chapman’s risk of self harm was not communicated by prison officers to the nurse carrying out the reception health screen. Consequently, potentially important information was not known to the reception nurse at the time that she assessed Mr Chapman. The concern that you have addressed to healthcare is this: “There does not appear to be a mechanism at reception whereby information relevant to self-harm…is routinely shared by prison staff with medical staff carrying out a reception medical screen including alerts on the CNomis system. As a result there appears to be a danger that significant alerts concerning a prisoner might not come to the attention of the reception nurse” It is, of course, recognised that it is important to share relevant information and the reception nurse would expect prison officers always to communicate any significant information regarding risk or welfare of which they were aware – whether this be contained in a PER document, on CNomis, or otherwise. As you were made aware during the inquest, it was not the practice, at the time, for the PER document to be passed by prison officers to the reception nurse and, as regards CNomis, this is not a system managed by healthcare and nurses are not routinely granted access to it. As you note in your report, you were advised during the inquest that the prison and healthcare intended to hold a meeting to discuss ways in which the sharing of information during the reception process might be improved. I can advise you that this meeting took place recently on March 1st. As a result of the meeting between the prison and healthcare it has been agreed that henceforth PER forms will be passed to the reception nurse as a matter of routine and the nurse must then document within the SystemOne record that the form has been received and considered. It is hoped that this “check” may be incorporated into the record system, as part of the existing reception health screen template, and this possibility is currently being explored. Thank you once again for bringing your concern to my attention.

Many Thanks

Head of Healthcare HMP Wymott