Steven May

Dear Mr McNamara, Inquest into the death of Mr Steven James on 25 2015 at HMP Ranby Thank you for your Regulation 28 Report of 16 March 2016. Your report has been passed to Equality, Rights and Decency (ERD) Group in the National Offender Management Service, as we are responsible for sharing learning from deaths in prison custody: am responding on behalf of the Secretary of State for Justice, NOMS and the Governor of HMP Ranby: You will be aware that healthcare at HMP Ranby is commissioned by NHS England and provided by Nottinghamshire Healthcare NHS Foundation Trust, and understand that the matters of concern that you have raised at points 1, 2 and 10 have been addressed separately by the Chief Executive of the Trust in a letter dated 13 April 2016, and by the Clinical Quality Manager at NHS England in a letter dated 5
2016. This response therefore addresses the matters of concern at points 3 to 9. (3) The_failure_of_prison staff_when preparing _the ACCT document to prepare as fulla note as possible For_example to follow the_subject_areas_suggested_in _the_narrative_accompanying sections 1-8 of_the_Assessment interview As you know, Prison Service Instruction (PSI) 64/2011 Safer Custody sets out the policy position, and the importance of fully recording and sharing information about risk is clear throughout; and particularly in chapter on information sharing: Chapter describes the Assessment, Care in Custody and Teamwork (ACCT) process, making reference to the need for effective record-keeping and requiring that the assessor record the outcome of the assessment interview on the ACCT plan: Staff at HMP Ranby were reminded of the need to make comprehensive records of all such interviews at a briefing on 23 March 2016. AlI ACCT documents at the prison are now being monitored by the Head of Safer Custody and the quality assurance check that is conducted addresses this point. At national level a review of the ACCT process was conducted in 2015 and NOMS is forward work on the recommendations, including issuing improved operational guidance for staff, developing a shorter and clearer ACCT plan and improving the content and delivery of safer custody training: (4)Reliance_bY_prison staff_on_verbal andor_oral handovers_of_information_rather_than written records_regarding the_deceased May May May May taking

PSI 64/2011 states that "it is vital that the on-going record contains sufficient information about progress and well-being of prisoner; This information is critical to ensure that the risk is managed appropriately and the CAREMAP remains relevant"_ At HMP Ranby a notice was issued in February 2016 reminding staff that those responsible for prisoner on an open ACCT must record all relevant information in the ACCT document; the wing observation book and on the P-NOMIS system: Both the prison and the healthcare provider have recently reviewed their procedures to ensure that systems are in place for information to be shared between prison and healthcare staff and recorded appropriately In order further to improve information sharing, meetings of the multi-disciplinary team for prisoners identified as being vulnerable or at risk of harm are held every two weeks, and any ongoing concerns are discussed and recorded: (5)The_involvement_in the ACCT process of_prison staff _possessing neither_relevant training nor the_appropriate rank PSI 64/2011 states that all staff in contact with prisoners must receive the foundation level 'Introduction to Safer Custody' training, and specific training is available for the roles of assessor and case manager. It also requires governors to provide ACCT refresher training according to local needs_ At HMP Ranby there are currently 30 trained assessors, 50 case managers and 464 staff of various grades who have received the foundation level training, and the Governor keeps these numbers under review: One of the recommendations of the national review of the ACCT process referred to above was for further work to clarify the bandlgrade requirements for staff in assessor and case manager roles and work on this is taken forward during 2016. (6)_The_ failure of_prison staff_to ensure the attendance of_a medical professional at the First Care Review It is a mandatory requirement of PSI 64/2011 that the first case review is attended by a member of healthcare staff. All case managers at HMP Ranby have been reminded that the initial case review must be attended by a member of healthcare staff, and the healthcare provider has adjusted its delivery model to make this possible_ (Z)The_selective training_of_prison staff_in emergency First Aid (namely the first member of prison staff_on the_scene of_the death was not trained in the administration of CPR and_was ignorant of the location of_and method of_use_of_defibrillators) PSI 29/2015 First Aid requires governors of public sector prisons to ensure that at all times such numbers of suitably trained first aiders as is sufficient and appropriate for the circumstances are available. These numbers must be determined by conducting a first aid risk assessment: First aiders must be trained to levels which are appropriate for the circumstances to either First Aid at Work (FAW) level or Emergency First Aid at Work (EFAW) level. The PSI becomes effective on 16 2016, and in preparation for its implementation, the Governor of HMP Ranby is reviewing the bandlgrade and numbers of staff who need to be trained in first aid. The prison currently has 61 staff trained in FAW and 73 in EFAW_ 86 staff have received training in the use of defibrillators, and all staff have been provided with information on the location and use of defibrillators through staff information notice issued on 16 July 2015. the the being being May

(8)_The_hesitancy of_the first member of_prison staff on the_scene _to enter_the deceased's cellin apparent adherence to an instruction not to enter_cells alone PSI 24/2011 Management and Security of Nights sets out the policy on how incidents should be managed during the night state when prisoners are locked in their cells. Night operating procedures must be agreed by the Governor and the Deputy Director of Custody and set out in the prison's Local Security Strategy (LSS), which must include the local procedures to be followed in a potentially life threatening situation where there are no other staff in the immediate vicinity. Where there appears to be an immediate danger to life, cells can be opened by an individual member of staff:.in such circumstances, the staff member must make every effort to obtain a response from the prisoner and then make a dynamic risk assessment of the situation based on what they can see through the observation panel and on what know of the prisoner. HMP Ranby has reinforced the relevant elements of its LSS and issued a staff notice to this effect on 9 September 2015. All staff have been given access to the LSS and their knowledge of it will be tested annually. (9) The_inadequacy of First Aid training provided to prison staff_in any event (namely_the administration of CPR bY prison staff whilst the deceased was Iying on a bed) PSI 29/2015 is clear that all training provided to NOMS staff must be delivered by competent instructors either by external providers from an approved list or trained and currently certificated NOMS trainers_ HMP Ranby is currently taking steps to ensure compliance with this element of the instruction in preparation for its implementation on 16 May 2016, alongside the review of the number of trained staff described in the response to point above_ Thank you for bringing these matters of concern to our attention. hope that the contents of this letter have been helpful in providing some national context and an assurance that the concerns that you have raised have been, or are being, addressed locally at HMP Ranby_

Dear Mr McNamara Report to prevent future deaths following inquest into the death of Steven James write in response to your Prevention of Future Deaths report dated of 16 March 2016 in order to provide you with the information you have requested_ This report was issued subsequent to the inquest into the death of Steven May, who died whilst a prisoner at HMP Ranby, where this Trust provides healthcare services The Trust welcomes any chance to improve the quality of its service and we have considered the concerns you raise in your report with care_ As you will be aware, the Trust commissions internal investigations whenever Serious Incidents (Sls) occur: The purpose of these SI reports is to look at the whole circumstances of the incident, set against best practice, and to identify opportunities for learning and improvement. In the context of any death in prison setting, the circumstances are always investigated by the Prisons and Probation Ombudsman: If there has been any healthcare involvement with prison, the Ombudsman is assisted by clinician, appointed by NHS England_ who carries out an independent clinical review. This ensures that whenever there is a fatality involving a patient of the Trust who is held in prison setting; there is both an internal and an external investigation. Where considered appropriate by the investigators, each of those investigations can make formal recommendations for changes in, or reviews of, clinical practice and management: Both an internal and an external investigation were conducted regarding Mr May's death: A copy of the Trust's internal Sl report was shared with your office_ The Trust took action in response to recommendations made in both its own Sl report, and the PPO report; prior to the inquest taking place. The actions taken by the Trust in response to these recommendations were set out in Head of Healthcare written and oral evidence at the inquest. Continued Stonewall 1oo _ The Resource , Duncan Macmillan House Porchester Road, Nottingham NG3 6AA TORdoO INVESTORS Silver Chair: Dean Fathers; Chief Executive: Ruth Hawkins IN PEOPLE PoSitire May

Coroner's Concerns Of the 10 concerns listed in the PFD report; (1), (2) and (10) relate to healthcare. will address each of these in turn. (1) The failure of reception nursing staff;, by reason of lack of training andlor instruction or lack of staff andlor time, to consult the deceased's historical medical notes prior to or during the reception interview. As have noted above the Trust's Serious Incident report made number of recommendations One of the recommendations was as follows: "In order to ensure there is good knowledge of the patient before they are located into the prison it is essential that previous records are reviewed to determine any immediate risk issues Whilst patient self-report is essential and vital it should not be relied on in isolation of clinical records. Prior to Mr May's death, staff were aware of the requirement to review patient's SystmOne notes to check for any relevant history during the first reception screen: Although this should have been done when Mr May was being reviewed during his first reception screen, it did not: In response to this recommendation all staff were reminded via primary care team meetings (minutes of the meetings have been emailed to all staff members) and during one to one sessions with their line manager of the importance of reviewing patient notes for information during the reception health screen. In evidence at the inquest confirmed that she was, at that time, both aware of the need to check for relevant medical history (in particular, any history of self harm/ suicide attempts) and routinely did so_ As set out in statement and oral evidence in recognition of the fact that there is limited time nurse on reception can spend with each individual prisoner , the Trust introduced key word search facility (i.e nurses can search words, such as 'mental health' or 'self-harm') This enables nurses to identify key entries in a patient's SystmOne medical history (which can be extensive if an individual is serving long sentence) very quickly: In addition to this, understand that gave evidence at the inquest that in November 2015 the Trust submitted business case to NHS England (the Trust's commissioner) seeking recurrent funding for further healthcare staff. This document was provided to you by the Trust's solicitors after the conclusion of the inquest: The funding requested was secured, with the exception of that for a paramedic post, which the Trust may bid for again in future As a result the Trust is now able to provide designated reception nurse, SO that nurses on reception do not experience the time constraints thatl would have experienced in 2015 due to her other duties_

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(2) The lack of experience andlor training of reception nursing staff in the field of mental health_ Individuals arriving into HMP Ranby can have history of physical illness, mental illness_ substance misuse or a combination of these All healthcare needs must be considered, not purely mental health in isolation_ Reception nurses are generally primary health nurses When an individual arrives into reception, the nurse reviews any relevant documentation and medication that is brought in with the patient and then completes general physical healthcare observations. After the nurse will complete a very detailed template of questions with the patient relating to their physical health, mental health and any history of substance misuse Further, as set out above reception nurses are trained to look back through patient's medical history and to search for key areas of concern such as history of self harm/suicide. If an individual has history of mental illness then the reception nurse will refer the individual to the Primary Mental Health Team. The Primary Mental Health Team will aim to have a appointment with that patient within 48 hours_(and must see the patient within 5 working days) As confirmed in evidence byl the Trust was compliant with this target in
2015. If reception nurse has significant concerns about patient;, can seek immediate assistance from member of the Primary or Secondary Mental Health Teams: (10) The accessibility of health andlor mental health care to inmates at weekends and during Bank Holidays. The Trust's resources are of course limited in accordance with its contract with NHS England. In 2015, the Trust was not commissioned to provide mental health services at HMP Ranby at a weekend Despite this service not being commissioned, the Trust had identified a need for weekend mental health cover and was providing limited cover by transferring resources from elsewhere (which is why was available on Sunday 24
2015). The Trust was in discussion with NHS England about securing extra resource for HMP Ranby around one year ago_ NHS England requested that evidence needed to be gathered to feed into its assessment of healthcare needs in connection with those aspects of healthcare which it commissions_ This led to the Trust instructing an independent company to complete Healthcare Needs Assessment ("HNA") The HNA identified that there was particularly high level of healthcare need at HMP Ranby and the demand for services was not fully met by the level of service commissioned by NHS England. It was identified that part of the added demand was fuelled by health problems caused by New Psychoactive Substances ("legal highs"). The business case set out; among other things, the demand that the Primary Mental Health Team was facing: In particular, it highlighted that the team had tried to deliver an out of hours service at weekends, however this had caused the commissioned Monday- Friday service to be stretched_ The business case set out that if NHS England provided funding for a Band 6 Primary Mental Health Nurse, increased the existing Band 5 post to a Band 6 post and met

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additional costs associated with unsocial hours, it would enable the Trust to provide safe an effective service 7 per week: understand that at the inquest, during her evidence_ lexplained that following the submission of the attached business case to NHS England in November 2015, NHS England acceded to all of the requested funding (save for the paramedic post), which amounts to just under E143,000. As is clear from the business case, the Trust has already taken action to address this concern_ The Trust has been recruiting to fill the new posts at HMP Ranby for which funding has been agreed: From the Trust's perspective, and also we understand from that of NHS England, this has been an effective example of partnership working that has also involved the prison service, who were supportive of the Trust's efforts to obtain the extra funding: The Trust cannot respond to the other concerns highlighted in the Prevent Future Death report as are matters for HM Prison Service andlor other parties_ Please do not hesitate to contact me should you require further information.