Kevin Dermott

Coroner's concerns

AI summary

While at HMP Durham, the deceased was left in a urine soaked cell during a hypomanic episode and a psychiatric referral was never completed; inadequate mental health cover at HMP Haverigg and a lack of suitable psychiatric care facilities at HMP Kirkham contributed to a failure to recognise relapse into depression at HMP Risley.

View full coroner's concerns

The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hypomanic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.

Responses

3 respondents

NHS England NHS / Health Body

13 Jun 2016 PDF

Action Planned

NHS England is working with other organisations to address the lack of secure psychiatric beds. Updated guidelines for transferring prisoners to secure mental health hospitals are due for final consultation in autumn 2016. (AI summary)

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Dear Mr Rheinberg; RE: Regulation 28: Report to prevent Future Deaths Mr Kevin Dermott; HMP Risley Thank you for your Regulation 28 Report which was issued on Monday 13 June 2016 following the inquest into the sad death of Kevin Dermott; who died at HMP Risley on 19
2014. would like to express my deep sympathy to Mr Dermott's family. Since April 2013 NHS England is the organisation responsible for the commissioning of healthcare in prisons following the implementation of the Health and Social Care Act (2012). Mr Dermott spent his time from entering prison on 26 September 2012 in four prisons until his death on Monday 19 2014 which covers the transition of healthcare commissioning from Primary Care Trusts to NHS England commissioning hubs_ wish to respond to your concern that the mental health facilities in prison were not sufficient enough to address the mental illnesses such as the deceased suffered. This includes concerns that there was seen to be inadequate consultant psychiatric support, lack of long-term care planning, lack of continuity of care and lack of hospital facilities to deal with acute psychiatric problems_ Since 1 April 2013 the commissioning of healthcare across the prison estate has under gone some major reprocurements, led by the local NHS England health and justice commissioning hubs_ In some local areas commissioners have used a 'prime provider' model which gives the prime contractor responsibility for the management and delivery of the whole care pathway, with parts of the pathway sub-contracted to other providers In other local areas commissioners have chosen to commission services on "separate lots" model; whereby the commissioner retains more direct oversight of the individual services_ Whatever the model local commissioners will always ensure that contractual compliance with the care pathway is in place. High quality care for all, now and for future generations May May

Better integration of health care services within prisons has also been by the development of a national set of service specifications for supported services (including GP and nursing services), mental health primary care substance misuse services_ The mental health service services and requirement for mental health services to provide specification outlines the model for mental health which enables an integrated stepped care to patients to flow seamlessly between mild moceriate and severe and enduring stages based on clinical need and include the provision of consultant psychiatrist These service specifications developed in December 2013 and set the outcomes and standaeds were the services including long-term care required from review of planning and continuity of care. A planned Sbesspecifications is underway to respond to the Health and Wel-Being Needs Assessments with substance misuse specification and mental health services for immigration removal centres underway and expected to be completed by the end of 2016 The review of the prison mental health specification will also align to the Ministry of Justice review 0f meneal aealenlin prisons as part of the prison reform agenda of which a date is to be set to commence the work This will provide NHS England with an opportunity to ensure lessons learnt from deaths in custody inform our commissioning responsibilities_ WitlstFeiglzedes supporting the National Offender Management Services (NOMS) with their review of the Person Escort Record (PER): This revised form that all current and relevant information (ncluding healths inforseaticormseheiarer one document and transfers with the prisoner held in reception into prison and police custody through to any subsequent prison transfer or release. The eolsout oPFe paper form pilot is still ongoing and work is being undertaken ensuring PER training Will be available to all operational staff ethg {9 to be launched by March 2017. The digital PERforatiorbeing piloted is expecped 6 prisons and NOMS are leading on this work couple of During the financial year of 2014/15, new data set in health & justice The Health & Justice Indicators of Performance' (HJIPs) called data set collects information was introduced, The on the delivery and outcome requirements NHS England are required to commission as part of their organisational Fesponsibilities and includes outcomes data on mental health serviceaprovisoa Formal reporting of this data commenced in April 2016 with the first data due to be submitted to NHS England in 2021616Thishdate fosthguaateroy the quarterly contract meetings between the part of commissioners and the prime providers regional health and justice NHS England recognises that there is a national issue regarding lack of secure Psychiatric beds which impacts on the timely transfer of acutely unwelk prisoere The Health and Justice commissioning team are working with colleagues in the NASt England Specialised Commissioning teams, Who are responsible forssecure Oeatalehealth provisionz and other partners in Department of Health;ONationa Offender Management Services and of Justice and Home Office to look at this issue and try to resolve it. Nes England Health and Justice and Specialised Commissioning teams have developed updated guidelines for the transfer oi prisoners to and remission frove High quality care for all, now and for future generations from during July Ministry

secure mental health hospitals. This guidance is due for final consultation in autumn 2016 prior to publication and until then the Department of Health 2011 guidelines remain extant. The HJIPs data set also contains transfer timelines to mental health secure units_ hope the information above addresses the concerns you have raised within your report and provide assurances that NHS England recognises your concerns and are working with number of organisations to identify and hopefully address the issues in an adequate manner: am grateful to you for bringing these matters to my attention:

HM Prison and Probation Service Central Government

19 Aug 2016 PDF

Action Planned

HMP Risley has increased the level and depth of management checks on ACCT documents, will issue a Governor's Order clarifying staff responsibilities, and has informed staff to contact the Safer Custody department for immediate ACCT reviews. Changes are planned for implementation by the end of September 2016. (AI summary)

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Dear Mr Rheinberg Thank you for your Regulation 28 report addressed to the Governing Governor of HMP Risley, concerning the recent inquest into the death of Kevin Dermott on 19 May 2014 at HMP Risley. Your report has been passed to the Equality, Rights and Decency (ERD) Group at NOMS headquarters, as we have responsibility for the policy on suicide prevention and self-harm management and for sharing learning from deaths in custody. have consulted with the Governor in formulating this response. You have identified number of matters of concern regarding the implementation of the Assessment; Care in Custody and Teamwork (ACCT) process at the prison, and will explain the steps that are being taken to address them: The level and depth of management checks on the ACCT process have been increased: All ACCT documents are checked daily by Offender Supervisors, and an additional weekly check by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking a sample of ACCT documents each week, and will continue to do so until he is satisfied that the standards have improved and that the relevant processes are embedded: A Governor's Order will be issued setting out clearly which member of staff is responsible for which ACCT documents at which time, encouraging personal ownership and ensuring accountability. Staff who have not completed an ACCT document satisfactorily be asked to account for their actions, and, where necessary, action will be escalated through a verbal warning; written warning or investigation for misconduct as appropriate. In support of this, all Offender Supervisors and Custodial Managers are briefed about the importance of the ACCT process In order to ensure that any concerns that are raised about a prisoner are being acted upon staff have been informed that must contact the Safer Cuslody department; who will organise an immediate ACCT review for that day- If the named Offender Supervisor cannot attend it will be escalated to the "Oscar" group (comprised of three Offender Supervisors) , and where are not available it will be further escalated to the duty Custodial Manager (who is available 24 hours) that this provides you with reassurance that your concerns are being acted upon. HMP Risley will have these changes in place by the end of September 2016.

Department of Health Central Government

15 Dec 2016 PDF

Noted

The Department of Health acknowledges the concerns, highlights its commitment to working with NOMS and NHS England, and notes that NHS England and NOMS will be responding separately. (AI summary)

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1 DEC 2016 From Nicola Blackwood MP Parliamentary Under Secretary of State for Public Health and Innovation Department Richmond House of Health 79 Whitehall London SWIA 2NS Mr N.LRheinberg 020 7210 4850 Senior Coroner for Cheshire West Annexe Town Hall Sankey Street Warrington Cheshire WA1 1UH 15 December 2016 Mv Thank you for your letter to Secretary of State about the death of Mr Dermott: am responding as the Minister with responsibility for prison health services at the Department of Health_ Please accept my apologies for the delay in responding was saddened to read of the circumstances surrounding Mr Dermott's death: Please pass my condolences to Mr Dermott's family and loved ones_ The safety and wellbeing of prisoners should be paramount which includes delivering high quality physical and mental health services that meet the needs of prisoners: The Department of Health is committed to working with the National Offender Management Service (NOMS) and NHS England;, as the commissioner of health and justices services, to ensure that this happens _ However; you have highlighted issues relating to Mr Dermott's care that demonstrate there is much more we need to do. would expect the prison service and NHS England to learn lessons where the care of Mr Dermott fell short of expectations in meeting his clinical needs and ensuring his safety; to prevent this happening again: have ensured that colleagues at NOMS have received copy of your report and asked them to write to you directly. The Government is committed to improving all prison health services, including mental health treatments; which is why NHS England has allocated approximately E523m for health and justice commissioning, including spending on mental health services in prisons in England in 2016/17. In February, the Government announced plans to trial six reform prisons, with full co- commissioning between governors and NHS England: Subject to a review of outcomes and performance, the Ministry of Justice will roll out this model across the prison estate in England from 2017 , supported by new legislation; The aim is to ensure that health services provided in prisons are more closely matched to the often specific needs of a particular establishment: Ruibo

Work is underway to improve the way health services in prisons are delivered including testing co-commissioning of health services between governors and NHS England, with governors having a greater say in defining prison health services in their prison, and budgets: We also welcomed the Mental Health Taskforce's Five Year Vision for Mental Health in February which recommends a non-custodial, integrated health and justice pathway to support offender mental health needs in community, including community sentences with a mental health treatment requirement (MHTR) and Liaison and Diversion (L&D) services_ NHS England published an implementation plan in to progress the NHS recommendations of the Five Year Vision and we will publish a strategic implementation plan later this year to progress the cross-Government recommendations_ Turning to the issues you raised in your report; you expressed concern that Mr Dermott's relapse into depression was not recognised and the jury concluded that his death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures_ You suggested that; mental health provision failings are endemic within prisons and that mental health facilities in prison are not adequate to address mental illnesses, justifying the need for a fundamental review. NHS England has been responsible commissioning health and justice services since 2013 . am aware that Professor Sir Bruce Keogh, National Medical Director, NHS England wrote to you on 4 August setting out the ways in which NHS England is improving standards of care through improving service specifications and developing performance indicators to raise the quality of services across the board_ also understand that Professor Sir Bruce Keogh's response has addressed the following other concerns: inadequate consultant psychiatric support; lack of long- term care planning; and" iii_ lack of continuity of care and lack of hospital facilities to deal with acute psychiatric problems: All prisoners should be entitled to an equivalent range and quality of treatment and services from the NHS as people in the community can expect; according to clinical need. NHS England conducts health and wellbeing needs assessments for each prison on a regular basis to ensure that healthcare provision is commissioned to meet the needs of that establishment Within prisons, a prisoner has a health assessment on arrival, particularly to establish the risk of self-harm and suicide and risk of harm others. AlI prisons have on-site primary health care teams who should provide mental health care, refer to talking therapies or refer for a further psychiatric assessment for serious mental illness: The specific issues you raise about the failure to properly observe Assessment; Care in Custody & Teamwork (ACCT) procedures are operational and should be addressed by NOMS. the July - for from

Department of Health With regard to the referral of Mr Dermott to mental health services, we expect that prisoners that are clinically assessed as requiring mental health treatment in hospital should be transferred without unnecessary delay. However; acknowledge that delays may occur and health and justice systems can work better together to make improvements. NHS England is now revising national guidance for ensuring the timely transfer of prisoners to hospital. hope that this information is useful. Thank you for bringing the circumstances of Mr Dermott's death to our attention_

Report sections

Investigation and inquest

On 23rd May 2014 I commenced an investigation into the death of Kevin Dermott born on 29th September 1963. The investigation concluded at the end of the inquest commencing on 23rd May 2016 and concluding on 7th June 2016. The conclusion of the inquest was that at some time between 19.00 and 20.43 on Monday 19th May 2014, the deceased hanged himself using a ligature attached to his bed in his cell on landing 3 at HMP Risley. The following matters contributed to his death namely, failure to procure adequate medical care, uphold adequate channels of communication and to follow the ACCT process according to its procedures.

Circumstances of the death

The deceased who had been diagnosed with bi-polar affective disorder was sentenced to a term of imprisonment. Whilst a prisoner at HMP Durham he suffered a severe hypomanic episode. Having been transferred to HMP Haverigg and then HMP Kirkham, he was sent to HMP Risley where, during a probable relapse in his condition into a depressive episode, he hanged himself.

Action should be taken

Evidence at the inquest emerged that up to 80% of prisoners have some mental health problem but that mental health facilities in prison were not adequate sufficiently to address mental illnesses such as the deceased suffered. In particular there was seen to be inadequate consultant psychiatric support, lack of long-term care planning, lack of continuity of care and lack of hospital facilities to deal with acute psychiatric problems. Such facilities as existed were seen to be inferior to the care which a mentally ill patient would receive in the community. The problem was seen as running through the prison service as a whole rather than an isolated problem within one prison establishment and was seen as justifying a fundamental review of mental health provision within the prison service.

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