Kevin Forster

Dear Sir Inquest touching the death of Kevin Anthony Forster Date of death: 14 September 2014 HMP Durham write in response to your report dated 28 November 2015 made under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. In response to your concerns relating to the existence and applicability of a substance misuse policy at HMP Durham; I confirm the following: G4S Forensic & Medical Services (UK) Ltd took over responsibility for provision of healthcare services at HMP Durham on 1 April 2015_ The contract does not include provision of GP and Pharmacy Services and a5 from 1 April 2015, Spectrum Community Health CIC was appointed to provide GPs, specialist substance misuse and Pharmacy Services at HMP Durham: Between 2011 and 31 March 2015, Care UK were the healthcare providers at the prison: Prior to 2011 healthcare services were provided by NHS England. understand NHS England operated a "Drugs Overdose" policy at the prison and it is my understanding this policy document was considered at the inquest touching the death of Mr Forster: This policy was written prior to 2011 by a specialist substance misuse nurse employed by the NHS. Following their appointment, Care UK produced new policy documents in relation to a number of practices and procedures at the prison. 'Drugs Overdose" policy document was not updated or re-written by Care UK: My recollection is that Care UK did not make "Drugs Overdose policy document available on the intranet or in the Healthcare folder containing hard copies of written policy documents It is my belief that the absence of a updated policy document is the reason why there appeared to be confusion on the part of the healthcare witnesses at the inquest regarding the existence and applicability of a "Drugs Overdose policy: In particular; whilst those nurses employed at the prison by the NHS prior to 2011 would have known about the existence ad content of the policy; were confused as to its application once Care UK took over the contract; and the policy document was not readily available on the intranet or in the Healthcare folder: 2 3 DFC "2015 GPs The they

After G4S took over the contract in April 2015, it became clear to me that the situation relating to the Overdose" policy required clarification. The previous policy was too rigid ad did not allow specialist practitioners to exercise their expertise and manage individuals a5 and appropriately as possible: therefore updated the Substance Misuse policy: The draft policy document was submitted to and approved by the G4S Clinical Governance Lead, prior to formal introduction ad implementation at the prison: Once approved, the Substance Misuse was introduced to all healthcare staff, A copy of the policy was sent by email to every member of healthcare staff, Some months after the introduction of the new Substance Misuse however; towards the beginning of September 2015,I was made aware there had been changes in clinical practice which meant the was outdated in some respects It was felt at this stage that clinical guidelines, would be a preferable; more flexible "policy" , preferable to formal Policy document; because clinical guidelines envisage all different situations and respond accordingly: Spectrum Community Health and G4S, in liaison with NHS England, therefore joint project; working together to update the procedures in operation at the prison. A GP employed by Spectrum Community Health, Dr and the Substance Misuse Clinical Lead, Deb have been tasked to work together to produce clinical guidelines relating to all substance misuse issues, including the treatment and care to be delivered to any patient presenting a5 under the influence of illicit drugs: The work is being undertaken in conjunction with NHS England: A draft report and overarching pathway for and Alcohol Recovery Teams was produced at the end of November 2015. Following consultation between all contributors, including NHS England, the pathway is not designed to be a weighty document; but one that all practitioners and prison staff can use to understand the Drugs and Alcohol Recovery Team pathway; guidance, protocols ad interventions: It is proposed the pathway features space to embed documents and to hyperlink to guidance A final briefing session is scheduled for 22 December 2015 to discuss the pathway and next steps, to ensure leaders are fully briefed on the content of the pathway and the next steps, prior to wider circulation: The belief in the clinical team is that clinical guidelines are preferable to an inflexible written policy; as given the varying circumstances of how individual incidents can present, clinical guidelines will not restrict the ability of doctors ad nurses to utilise clinical discretion and decision making, into account all the aspects of the patient's presentation, clinical observations and other external factors. Clinical guidelines will enable the healthcare professionals to respond with absolute clarity to ensure individual patients receive the most appropriate treatment and care for their precise circumstances and symptoms The clinical guidelines are intended for implementation at all prisons within the North East Cluster and therefore it is essential that the guidelines are suitable &d safe for implementation at each of the different establishments within the North East Cluster; before are implemented: This will ensure consistency and suitability of approach, regardless of the establishment at which the patient is resident It is also an important reason why clinical guidelines are preferable to an inflexible policy document; to allow more flexibility in terms of treatment and care; to suit an individual's needs; within the structure of the clinical guidelines. G4S has appointed, on a consultancy basis, a substance misuse specialist doctor, Dr Martin Von Fragstein, to oversee the content; form and appropriateness of the clinical guidelines and to act as G4S' advisor on any substance misuse issue. The following further steps have taken to address your concerns surrounding other issues arising at the inquest: Client Conf dential 'Drugs safely Policy Policy; Policy began Bray; Miller, Drugs key taking they been

A request has been made to prison officers' Management to inform off cers at staff meetings that they are advised repont any suspicions of substance misuse (whether alcohol healthcare staff If there is any suspicion whatsoever then repart should be made t0 drugs) to healthcare We have intraduced; under the leadership of Dr Bray monthly training event spec fic t0 all of substance misuse issues which is held monthly on afternoon in the Prison Tra aspects ning Centre training event is open to all staff at the prison from all disciplines of the various organisat ons within the prison and wider region, both healthcare staff and d scipline staff Each session usua ly lasts for couple of hours: The training is mixture of white board discussion_ disciplinary discussions sharing 'nformation an group wark Mult- experiences and clinical reviews This training reintorces the senousness substance misuse and overdose IsSues and erphasises the inappropriateness and unacceptability of attitudes of complacency and acceptance towards the issues. Clinical and non clinical staft attend the training which Improves knowledge Iiaison and understanding on all aspects 0f substance m Suse within the custodial env ronment; a5 weli a5 learning and intelligence from the w' der community: regionally and naltionally Substance misuse training is also provided by the organisation L fel ne; which emplays the none clinical Drugs &nd Alcohol Recovery Team at HMP Durham; which focuses on psycho social ssues; undertaking a similar role to one undertaken by counsellors; and which provides psychasocial in relation to addictions with n the prison. support clinical guidelines being developed for substance misuse issues will include treatment template be Included on SystmOne for use in substance misuse cases The treatment plan plan will include all relevant care options including the requirement for care pian and regu ar observations Healthcare staff have been reminded of the requirement and Importance full and contemporaneous notes in each patient's medical records It Is my understanding that if ay individual '$ found in medical distress the first person to find the Individual has responsibility for _ the correct emergency code: As soon 35 code blue Is called; automatically triggers Ihe of an ambulance by the prison' $ control room staff On 4 November 2015,at a full stalf meeting of the prison, Mr Tim Ailen emphasised the need for the correct codes to be called in an emergency It is also planned that posters wi [ be sited for use in discipline staff areas and training repeated t0 prison officers the carrect allocation of codes in healthcare emergency Recent incidents related to significant increase in the illicit use of new psychoactive substances the Prison, have demonstrated high degree of cooperation and ,oint working between both discipline and healthcare staft; witn patients being closely monitored in wing environment Or if deemed necessary for lhe individual patient $ circumstances; transferred t0 the healthcare ent department or external hospital, until clinically stable trust my response addresses the concerns outlined n your recent report

Ministryof JUSTICE HMP National Offender DURHAM Management Service National Offender Management Service North East Area HMP Durham Old Elvet Durham DH1 3HU Telephone 0191 332 3600 Fax 0191 332 3401 14th January 2016 Statement for HM Coroner_in relation to the Emergency Code Protocol Sir Following the death of Mr Kevin Anthony Forster on 14th September 2015, while in custody at HMP Durham, the following actions have already been taken by the prison to ensure all staff have a full understanding of the Emergency Code Protocol which covers the use of Codes Blue and Red. These steps were taken prior to the Inquest occurring and were in response to the comments made by the Prison Probation Ombudsmen Report and also the prison'$ own learning exercise that was undertaken following this death: All current staff either directly employed, those employed by HM Prison Service or non-directly employed, those employed by partner agencies for example G4S and Manchester College have signed to say they have full understanding of the protocol and how to implement it: Line managers have satisfied themselves prior to staff signing that the staff members are fully aware as to the protocol works by gauging there verbal responses to the protocol: All staff have been issued with pocket sized cards explaining the protocol_ All residential areas which are the wings on which prisoners Iive have displaved the protocol in bold colours in prominent places which are A4 size_ These posters can be located in the main offices which everyone attending a wing must report to. Governors Notice to Staff has been issued to ensure that all new staff either directly or non-directly employed attend the Safer Custody department and receive a full explanation of the Emergency Code Protocol from how wing

as part of the joining process. When safer custody staff are satisfied have full understanding sign to this effect and are issued with a pocket size card from the Safer Custody department: The Emergency Protocol has been an agenda item on monthly team meetings with staff and the protocol fully explained: It is also discussed at the Safer Prisons meeting a5 part of a wider discussion on deaths in custody: The Deputy Governor has addressed the emergency protocol issue with all functional heads at meetings and this has been cascaded to staff by line managers The Governor has issued a notice to staff which has been sent out by email and is on the intranet: The Governor also used a full staff meeting to raise this issue with staff.