CNWL NHS Trust
NHS / Health Body
Action Taken
CNWL NHS Trust has clarified report request procedures with HMPPS, ensured report requests are communicated to consultants promptly, updated care plan templates to include release planning, audited CPA meetings to improve attendance, and launched an Offender Care Transformation Board to reduce self-harm and avoid unexpected deaths. (AI summary)
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Dear Mr Thorogood,
Re: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FOLLOWING THE INQUEST OF MS SARAH REED
I write in response to the Regulation 28 Report, issued by HH Sir Peter Thornton QC, following the inquest into the death of Ms Sarah Reed.
Central and North West London NHS Foundation Trust deeply regret the death of Ms Reed and the distress that this has caused her family.
We have noted the matters of concern raised in the Regulation 28 Report. We accept these and below outline our responses to them, current processes and intended actions we intend to take over the next 12 weeks.
A. Fitness to Plead Reports We have had a discussion with Her Majesty’s Prison and Probation Service (HMPPS) who have agreed to clarify the process and procedure for the provision of psychiatric reports to Courts.
Producing psychiatric reports, including in relation to fitness to plead and sentencing, is not something we do routinely within Offender Care services. Notwithstanding this, we fully accept that there was a delay in the communication to the responsible clinician in this case the request for this to be provided to the Court.
Under normal circumstances, the request should be communicated to the Consultant carrying clinical responsibility for the service, and then a decision is made as to how best to undertake this work. If the Consultant is unable to complete this work, the Court is informed so alternative experts can be instructed.
It now forms part of our Standard Operating Procedures that any requests for reports are communicated to the Consultant as soon as they are received; this includes instructions from the Court, defence solicitors, Crown Prosecution Service and/or any other relevant external agencies including Probation Services.
B. ACCT Reviews and Observations CNWL Offender Care have developed a “Roles and Responsibilities for Attendance at ACCT Reviews” Local Operating Procedure for all of our staff at our prison sites. This has been written in conjunction with NOMS Prison Service Instruction 64/2011 and has been operationalised at all of our prison sites.
The aim of this document is to give clear guidance to all healthcare staff about what is expected before, during and after planned and unscheduled ACCT reviews.
It is part of our procedures that registered healthcare professionals represent healthcare at ACCT reviews. This includes registered nurses, psychologists, social workers, doctors and/or occupational therapists. Where a healthcare professional is not registered, for example a Healthcare Assistant or Mental Health Associate Practitioner, and is familiar with the prisoner, then they can attend in addition to the registered professional.
Our procedures are comprehensive and explain:
Our response in hours and out of hours; Who and how to update records both on prison systems and our own electronic patient record; How we assess risk and complexity; and What actions we take following a review and our role when making a decision to close an ACCT. Prior to attending an ACCT review it is the responsibility of the Healthcare Professional to review SystmOne notes and fully update themselves of the current situation, relevant history and risk factors in addition to any recent ACCT reviews.
During the ACCT review the attending Healthcare Professional is expected to contribute to the review updating the multi-disciplinary team on any outstanding care map actions.
The Healthcare Professional should be vocal in any concerns they have and ensure that they are documented within the ACCT review. This includes decisions regarding observation levels, which are considered jointly by the ACCT Manager and the attending Healthcare Professionals. Following the ACCT review, the Healthcare Professional is responsible for making an entry onto the medical records using the appropriate template in addition to the ACCT book.
It is expected that all Healthcare Professionals attending ACCT reviews should have attended ACCT training provided by the prison and attend refresher training every three years.
In addition, CNWL Offender Care has developed its own bespoke training for the management of harm and suicide in prison environments. This training forms part of our mandatory training list and is retaken annually by all staff. Across Offender Care,
we are currently 94% compliant with this requirement. Statutory and mandatory training compliance is monitored via internal CNWL quality systems.
C. CPA Meeting
Care Programme Approach (CPA) is the national framework for the mental health services assessment, care planning, review, care co-ordination, and service user and carer involvement focussed on recovery.
The framework includes CPA and Lead Professional Care (LPC) arrangements. CPA is for those who have more complex needs, are at most risk or have severe and enduring mental illness. Lead Professional Care (LPC) is for people who need secondary mental health services but have more straightforward needs, for example, contact with only one professional or one agency requiring a more simple care plan.
There is a lack of guidance specific to CPA in prison and as such, there lacks a consistent approach within prison mental health services nationally, not only in the allocation of cases to CPA, but also in the timing of reviews.
Decisions about whether to allocate a particular case to CPA or LPC must be based on current assessment information and discussion in the care team, including services users and any carers involved. Where a prisoner is referred to the Mental Health Services and is already subject to CPA (from the community or a different prison) then it is expected that their care will continue under CPA. Where a person is awaiting transfer to hospital under Sections 47/49 or 48/49 of the Mental Health Act 1983 (as amended), it is expected that they are managed under CPA.
CNWL Offender Care services align our approach to CPA with current national practice. That is to say, any prisoner subject to CPA would be expected to have had a CPA review within 6 months of reception into custody, and further, a physical health check on an annual basis. We monitor this internally.
Further, our prison services assess new admissions within five days of arrival unless considered emergency, where they would be seen within four hours, or urgent, when they would be seen within 48 hours.
We are aware of the Jury’s conclusions in regards to medication management in the case of Ms Reed. Clinicians who prescribe are autonomous practitioners, making decisions and rationale for medication management. They also use multi-disciplinary team discussions between clinicians to consider alternative when treating individuals who are mentally unwell.
We accept that in this case a CPA meeting should have been arranged sooner. Ms Reed’s mental health and social functioning had deteriorated to the degree that this should have been prioritised. Further, we recognise that a CPA meeting would have allowed more detailed discussion regarding medication management.
As a result of this case CNWL Offender Care has produced prison specific guidance highlighting these requirements which has been disseminated to all prison sites
regarding expectations around CPA management, for comment. We expect this to be formally ratified as a new policy by 1 October 2017.
D. Visits We have had a discussion with HMPPS who have agreed to provide a response regarding the procedure for cancelling visits.
E. Notification of a Prisoner’s Release A new discharge policy – “Continuity of Care on Release/Discharge or Transfer from Prison” has been written by CNWL Offender Care. This has been written in line with the recently published NICE guidance (Physical Healthcare of People in Prison (NG57) 2 November 2016, and will be used across all CNWL Offender Care sites. Once ratified, by 1 October 2017, the below will become standard and expected practice.
In regard to carrying out a pre-release health assessment for people with complex needs, this will be led by primary healthcare and involve multidisciplinary team members and the prisoner. It will take place at least 1 month before the person’s planned release date. For people who may be in prison for less than 1 month, pre- release health assessments will be planned during their second health assessment.
The following is included in the care summary and post-release action plan for all prisoners:
Any significant health events that affected the person while they were in prison, for example new diagnoses, hospital admissions and instances of self- harm; Any health or social care provided in prison; Details of any on-going health and social care needs, including medicines they are taking, mental health and/or substance misuse; Future health and social care appointments, including appointments with, secondary and tertiary care, mental health services, substance misuse and recovery services, and, social services.
The prisoner will be given a copy of the care summary and plan post-release and help given to those who are being released from prison to find and register with a community GP, if they were not previously registered. Before any individual with diagnosed mental health problems is released, we will liaise with services that will be providing care and support to them after they leave prison, for example referral to community mental health services, if appropriate, on release.
This will include (as needed):
Primary care; Secondary and tertiary specialist services (for example, HIV, TB, oncology); Mental health or learning disability services; Substance misuse services;
National Probation Service; Community Rehabilitation Company (CRC); Social Services; Family or carers; External agencies such as home care.
Finally, there are a number of other areas that CNWL Offender Care continues to work across our estate to ensure the safety, effectiveness and responsiveness of the services we provide across our entire Offender Care estate. These include:
Staffing, recruitment and workforce planning
We have employed a dedicated Recruitment and Retention Lead for the directorate. All advertisements and job descriptions, including bank staff, have been updated. We are investing in recruitment incentives, such as welcome bonuses and enhanced benefits for staff. We monitor recruitment activity weekly and have relationships with regular temporary staff to ensure our units are safely staffed and we provide continuity of care. We continue to develop and innovate workforce planning by implementing new roles such as engaging pharmacists to run pharmacy-led clinics that support medication optimisation.
Benchmarking
Offender Care has been reviewed in line with recommendations set out in the “Learning from PPO investigations – Prisoner Mental Health, January 2016” and we are currently auditing against the recently released NICE guidance for prison primary and mental health service delivery. We are also currently finalising our suicide reduction strategy which will be completed for distribution amongst our prison estates by 1st October 2017.
Training
We have a range of training including statutory and mandatory, suicide and self-harm awareness, and, ACCT and continue to monitor staff compliance with it. Currently our Offender Care Services are 94% compliant with our statutory and mandatory training requirements.
Learning lessons
We have developed a Clinical Oversight Group to review all serious incidents. This group aims to reduce prisoner’s risk to self, while examining, in detail, emerging themes from serious incidents and near misses. The meeting is attended by the Trust’s Lead for Serious Incidents, ensuring lessons can be shared and learning actioned.
The Trust has also recently launched an Offender Care Transformation Board with an ambition to ensure that all patients in a custodial setting have timely access to quality physical and mental healthcare services that meet their needs. The Board will drive strategy to reduce self-harm and avoid unexpected deaths. It will also seek
assurance that learning from inspections and Coroner reports are fully embedded across our entire Offender Care portfolio. The Board meets fortnightly and formally report to the Divisional Board and Trust Executive Board.
Further, we continue to work closely with NHSE Commissioners to ensure that our services are commissioned and resourced appropriately to meet the level of acuity we are currently witnessing, both nationally, and within our service delivery units.
I hope this provides you with sufficient assurance that the Trust has taken appropriate action following the death of Ms Reed, and has accepted the recommendations and continues to work to improve the service we provide. If you have any questions or comments on the above please contact me directly on the numbers above.
I would like to conclude by saying that the Trust is passionate about good health care in prisons. Any failing or omission is taken very seriously and for the sake of future people we care for and in memory of Sarah Reed’s tragic death, we will work tirelessly to make improvements in care.
Re: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FOLLOWING THE INQUEST OF MS SARAH REED
I write in response to the Regulation 28 Report, issued by HH Sir Peter Thornton QC, following the inquest into the death of Ms Sarah Reed.
Central and North West London NHS Foundation Trust deeply regret the death of Ms Reed and the distress that this has caused her family.
We have noted the matters of concern raised in the Regulation 28 Report. We accept these and below outline our responses to them, current processes and intended actions we intend to take over the next 12 weeks.
A. Fitness to Plead Reports We have had a discussion with Her Majesty’s Prison and Probation Service (HMPPS) who have agreed to clarify the process and procedure for the provision of psychiatric reports to Courts.
Producing psychiatric reports, including in relation to fitness to plead and sentencing, is not something we do routinely within Offender Care services. Notwithstanding this, we fully accept that there was a delay in the communication to the responsible clinician in this case the request for this to be provided to the Court.
Under normal circumstances, the request should be communicated to the Consultant carrying clinical responsibility for the service, and then a decision is made as to how best to undertake this work. If the Consultant is unable to complete this work, the Court is informed so alternative experts can be instructed.
It now forms part of our Standard Operating Procedures that any requests for reports are communicated to the Consultant as soon as they are received; this includes instructions from the Court, defence solicitors, Crown Prosecution Service and/or any other relevant external agencies including Probation Services.
B. ACCT Reviews and Observations CNWL Offender Care have developed a “Roles and Responsibilities for Attendance at ACCT Reviews” Local Operating Procedure for all of our staff at our prison sites. This has been written in conjunction with NOMS Prison Service Instruction 64/2011 and has been operationalised at all of our prison sites.
The aim of this document is to give clear guidance to all healthcare staff about what is expected before, during and after planned and unscheduled ACCT reviews.
It is part of our procedures that registered healthcare professionals represent healthcare at ACCT reviews. This includes registered nurses, psychologists, social workers, doctors and/or occupational therapists. Where a healthcare professional is not registered, for example a Healthcare Assistant or Mental Health Associate Practitioner, and is familiar with the prisoner, then they can attend in addition to the registered professional.
Our procedures are comprehensive and explain:
Our response in hours and out of hours; Who and how to update records both on prison systems and our own electronic patient record; How we assess risk and complexity; and What actions we take following a review and our role when making a decision to close an ACCT. Prior to attending an ACCT review it is the responsibility of the Healthcare Professional to review SystmOne notes and fully update themselves of the current situation, relevant history and risk factors in addition to any recent ACCT reviews.
During the ACCT review the attending Healthcare Professional is expected to contribute to the review updating the multi-disciplinary team on any outstanding care map actions.
The Healthcare Professional should be vocal in any concerns they have and ensure that they are documented within the ACCT review. This includes decisions regarding observation levels, which are considered jointly by the ACCT Manager and the attending Healthcare Professionals. Following the ACCT review, the Healthcare Professional is responsible for making an entry onto the medical records using the appropriate template in addition to the ACCT book.
It is expected that all Healthcare Professionals attending ACCT reviews should have attended ACCT training provided by the prison and attend refresher training every three years.
In addition, CNWL Offender Care has developed its own bespoke training for the management of harm and suicide in prison environments. This training forms part of our mandatory training list and is retaken annually by all staff. Across Offender Care,
we are currently 94% compliant with this requirement. Statutory and mandatory training compliance is monitored via internal CNWL quality systems.
C. CPA Meeting
Care Programme Approach (CPA) is the national framework for the mental health services assessment, care planning, review, care co-ordination, and service user and carer involvement focussed on recovery.
The framework includes CPA and Lead Professional Care (LPC) arrangements. CPA is for those who have more complex needs, are at most risk or have severe and enduring mental illness. Lead Professional Care (LPC) is for people who need secondary mental health services but have more straightforward needs, for example, contact with only one professional or one agency requiring a more simple care plan.
There is a lack of guidance specific to CPA in prison and as such, there lacks a consistent approach within prison mental health services nationally, not only in the allocation of cases to CPA, but also in the timing of reviews.
Decisions about whether to allocate a particular case to CPA or LPC must be based on current assessment information and discussion in the care team, including services users and any carers involved. Where a prisoner is referred to the Mental Health Services and is already subject to CPA (from the community or a different prison) then it is expected that their care will continue under CPA. Where a person is awaiting transfer to hospital under Sections 47/49 or 48/49 of the Mental Health Act 1983 (as amended), it is expected that they are managed under CPA.
CNWL Offender Care services align our approach to CPA with current national practice. That is to say, any prisoner subject to CPA would be expected to have had a CPA review within 6 months of reception into custody, and further, a physical health check on an annual basis. We monitor this internally.
Further, our prison services assess new admissions within five days of arrival unless considered emergency, where they would be seen within four hours, or urgent, when they would be seen within 48 hours.
We are aware of the Jury’s conclusions in regards to medication management in the case of Ms Reed. Clinicians who prescribe are autonomous practitioners, making decisions and rationale for medication management. They also use multi-disciplinary team discussions between clinicians to consider alternative when treating individuals who are mentally unwell.
We accept that in this case a CPA meeting should have been arranged sooner. Ms Reed’s mental health and social functioning had deteriorated to the degree that this should have been prioritised. Further, we recognise that a CPA meeting would have allowed more detailed discussion regarding medication management.
As a result of this case CNWL Offender Care has produced prison specific guidance highlighting these requirements which has been disseminated to all prison sites
regarding expectations around CPA management, for comment. We expect this to be formally ratified as a new policy by 1 October 2017.
D. Visits We have had a discussion with HMPPS who have agreed to provide a response regarding the procedure for cancelling visits.
E. Notification of a Prisoner’s Release A new discharge policy – “Continuity of Care on Release/Discharge or Transfer from Prison” has been written by CNWL Offender Care. This has been written in line with the recently published NICE guidance (Physical Healthcare of People in Prison (NG57) 2 November 2016, and will be used across all CNWL Offender Care sites. Once ratified, by 1 October 2017, the below will become standard and expected practice.
In regard to carrying out a pre-release health assessment for people with complex needs, this will be led by primary healthcare and involve multidisciplinary team members and the prisoner. It will take place at least 1 month before the person’s planned release date. For people who may be in prison for less than 1 month, pre- release health assessments will be planned during their second health assessment.
The following is included in the care summary and post-release action plan for all prisoners:
Any significant health events that affected the person while they were in prison, for example new diagnoses, hospital admissions and instances of self- harm; Any health or social care provided in prison; Details of any on-going health and social care needs, including medicines they are taking, mental health and/or substance misuse; Future health and social care appointments, including appointments with, secondary and tertiary care, mental health services, substance misuse and recovery services, and, social services.
The prisoner will be given a copy of the care summary and plan post-release and help given to those who are being released from prison to find and register with a community GP, if they were not previously registered. Before any individual with diagnosed mental health problems is released, we will liaise with services that will be providing care and support to them after they leave prison, for example referral to community mental health services, if appropriate, on release.
This will include (as needed):
Primary care; Secondary and tertiary specialist services (for example, HIV, TB, oncology); Mental health or learning disability services; Substance misuse services;
National Probation Service; Community Rehabilitation Company (CRC); Social Services; Family or carers; External agencies such as home care.
Finally, there are a number of other areas that CNWL Offender Care continues to work across our estate to ensure the safety, effectiveness and responsiveness of the services we provide across our entire Offender Care estate. These include:
Staffing, recruitment and workforce planning
We have employed a dedicated Recruitment and Retention Lead for the directorate. All advertisements and job descriptions, including bank staff, have been updated. We are investing in recruitment incentives, such as welcome bonuses and enhanced benefits for staff. We monitor recruitment activity weekly and have relationships with regular temporary staff to ensure our units are safely staffed and we provide continuity of care. We continue to develop and innovate workforce planning by implementing new roles such as engaging pharmacists to run pharmacy-led clinics that support medication optimisation.
Benchmarking
Offender Care has been reviewed in line with recommendations set out in the “Learning from PPO investigations – Prisoner Mental Health, January 2016” and we are currently auditing against the recently released NICE guidance for prison primary and mental health service delivery. We are also currently finalising our suicide reduction strategy which will be completed for distribution amongst our prison estates by 1st October 2017.
Training
We have a range of training including statutory and mandatory, suicide and self-harm awareness, and, ACCT and continue to monitor staff compliance with it. Currently our Offender Care Services are 94% compliant with our statutory and mandatory training requirements.
Learning lessons
We have developed a Clinical Oversight Group to review all serious incidents. This group aims to reduce prisoner’s risk to self, while examining, in detail, emerging themes from serious incidents and near misses. The meeting is attended by the Trust’s Lead for Serious Incidents, ensuring lessons can be shared and learning actioned.
The Trust has also recently launched an Offender Care Transformation Board with an ambition to ensure that all patients in a custodial setting have timely access to quality physical and mental healthcare services that meet their needs. The Board will drive strategy to reduce self-harm and avoid unexpected deaths. It will also seek
assurance that learning from inspections and Coroner reports are fully embedded across our entire Offender Care portfolio. The Board meets fortnightly and formally report to the Divisional Board and Trust Executive Board.
Further, we continue to work closely with NHSE Commissioners to ensure that our services are commissioned and resourced appropriately to meet the level of acuity we are currently witnessing, both nationally, and within our service delivery units.
I hope this provides you with sufficient assurance that the Trust has taken appropriate action following the death of Ms Reed, and has accepted the recommendations and continues to work to improve the service we provide. If you have any questions or comments on the above please contact me directly on the numbers above.
I would like to conclude by saying that the Trust is passionate about good health care in prisons. Any failing or omission is taken very seriously and for the sake of future people we care for and in memory of Sarah Reed’s tragic death, we will work tirelessly to make improvements in care.