Dean Saunders

Dear Mrs Beasley-Murray, Re: Regulation 28: Report to prevent Future Deaths Mr Dean Saunders, HMP Chelmsford Thank you for your Regulation 28 Report which was issued on Friday 17 February 2017 2016 following the inquest into the sad death of Dean Saunders, who died at HMP Chelmsford on January 2016. would like to express deep sympathy to Mr: Saunders' family: In your Regulation 28 Report you have raised two concerns for NHS England which are addressed in the responses below: Concern 2: For NHS England and SEPT The absence of a written record Of the "best practice" forensic pathway referred to byl in his evidence, and consideration of whether the transfer of individuals such as Dean to prison is indeed "best practice" , taking into account the consequent in transfer and the suitability of the prison environment for mentally disordered individuals. The following information describes the commissioning arrangements for healthcare for someone being held in police custody: Police custody healthcare at Basildon is commissioned by the Essex Police and Crime Commissioner and is provided by G4S who are responsible for assessing people as being fit to be detained, interviewed and charged, where requested to by custody officer: NHS England commission South Essex Partnership Trust to provide Liaison and Diversion (L & D) services for Essex, which includes Basildon Police Station. Where police custody staff have a concern around an individual's vulnerabilities, referral is made to the L & D service who will assess and identify any mental High quality care for all, now and for future generations my delay

health, learning disability, substance misuse andlor other treatment services to provide options to divert from or work alongside other criminal justice interventions The decision to remand someone to prison is made by the courts and, if required, be informed by an assessment of their current presenting health and vulnerabilities. In this case, the decision to remand Mr Saunders to HMP Chelmsford was made by Basildon Magistrates Court. The NHS England Liaison and Diversion Standard Service Specification 2015 (attached at Appendix A for information) outlines that the service provider will develop care pathways with identified local health and social care services in partnership with key stakeholders, including community rehabilitation companies, action teams and local mental health providers, and other service providers. Concern 5: For NHS England The resilience of psychiatric cover at Chelmsford prison, which would need to be raised with NHS England who commission such services and decide on budget: NHS England commissions healthcare in prisons using an outcomes-based service specification: NHS England (Midlands and East) is responsible for the performance management of the healthcare contract: The provider; Care UK, is required to submit quarterly data on a range of qualitative and activitylbased performance indicators: NHS England (Midlands and East region) has considered the resilience of the psychiatric care service at HMP Chelmsford, a category B local prison: Care UK are the current providers of mental health services at HMP Chelmsford and deliver a total of 5 sessions of psychiatry per week for population of 710 men: A health needs assessment was conducted in 2016 by an independent author who concluded that the overall provision of psychiatry cover at HMP Chelmsford meets the needs of the population: The Health Needs Assessment is provided at Appendix B At the time that Mr Saunders was in HMP Chelmsford the regular psychiatrist was on annual leave. A cover psychiatrist saw Mr Saunders and provided the first signature for the document which would have supported his transfer to secure mental health placement: Due to the regular prison psychiatrist's leave there was five day delay in obtaining the required second signature for the Mental Health Assessment document. This was followed up by NHS England commissioners with Care UK who informed the commissioners that it had circulated a document to all staff which provides details of names and contact details of medical staff who can sign Mental Health Assessment documents. This will ensure that there are no further recurrences of delays in completing the required documentation and transfers: In addition, from 27 2017 , a new provider will be delivering healthcare at HMP Chelmsford. The new provider is a local mental health provider and the psychiatry service will be supported by a wider service than currently offered, High quality care for all, now and for future generations will drug key the May

providing greater access to a pool of psychiatrists who could provide signatures if required. We acknowledge the concerns you have expressed and hope that this response provides confirmation that those concerns are being addressed in national policy or practice. am grateful to you for bringing these matters to my attention:

Dear Madam

Regulation 28: Prevention of Future Deaths report The inquest touching the death of Dean Gary Saunders HMP Chelmsford Date of death: 4th January 2016

Thank you for your Regulation 28 Prevention of Future Deaths Report dated 17 February 2017 issued to Care UK following the inquest into the death of Mr Dean Saunders. Care UK is the provider of primary healthcare and mental health services at HMP Chelmsford. Care UK would like to express its condolences to Mr Saunders’ family and friends. The matter of concern to you in so far as it relates to Care UK are highlighted in bold with the response set out below each concern. I am responding in my capacity as National Medical Director for Health in Justice

1. The lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction (if the PSI and NHS England “good practice” is compared). Given the rationalisation of the process is still a “work in progress”, the family consider that it should be given urgent consideration.

I can confirm what I explained in evidence at the inquest. The Department of Health’s 2011 Good Practice Procedure Guide on the transfer and remission of adult prisoners under Section 47 and Section 48 of the Mental Health Act sets out the procedure that is best practice to be followed in order to enable transfer of a patient under those sections from prison to a secure mental health facility.

The Transfer Policy that had been drafted locally at HMP Chelmsford is at odds with that best practice. However, the policy at HMP Chelmsford had been developed locally through the mental health team’s experience of how best to speed up the transfer process. At the date of the inquest, this Transfer Policy was also a work in progress and not the perfected version.

As I discussed in evidence, the Mental Health Pathway has been revamped and further work has been undertaken with the team to improve mental health services in HMP Chelmsford. .

This revamped Mental Health Pathway is a strategic national policy and local sites develop local operating policies to describe how they will meet the requirements of the pathway. This will include a local Transfer Policy to outline the local processes (see below).

The Mental Health Pathway was initially developed by Care UK in Yorkshire with a group of clinical staff, NHSE commissioners and service users. The pathway has been subsequently reviewed by a group of Care UK experienced senior clinicians and further adapted to ensure it takes account of best practice. The work adapting the pathway from the Yorkshire model involved a multidisciplinary group including the national medical director, national lead nurse, regional manager, a head of healthcare and mental health team leader, all of whom have a wealth of experience with managing mental health in prisons. The pathway has been out to a wider group for consultation, including Care UK subcontractors (mental health trusts) and has been further amended to take account of their comments.

The new pathway has been shared with the local team at HMP Chelmsford and work has been undertaken to embed changes to clinical practice. It has been further shared nationally with Care UK regional managers and senior clinical leaders.

Under the transfer pathway section, the first referral to the secure mental health facility should encompass the first clinical recommendation under the Mental Health Act in order to trigger the transfer process. Exactly which secure mental health facility a patient is referred to will depend on a number of factors including where in the country the prison is located, where the prisoner lived before coming into prison and where a bed is available. Each prison will add its own local detail (such as contact details) to their Transfer Policy.

The new Mental Health Pathway was formally signed off at the quality assurance meeting held on 28 March 2017 and is currently being rolled out across all Care UK sites via a series of mental health workshops which will examine processes and quality of care provided. These workshops are facilitated by senior clinicians to support local teams to continuously improve the quality of their mental health service provision.

As you may be aware, there is due to be a change of healthcare provider within HMP Chelmsford and, therefore, the mental health pathway within the establishment may change.

I trust that the above response provides the information that you require but please do not hesitate to contact me if Care UK can be of any further assistance or if you would like copies of the Mental Health Pathway and Transfer Policy for HMP Chelmsford.