Source · Prevention of Future Deaths

Samuel Gale

Ref: 2015-0454 Date: 23 Oct 2015 Coroner: John Sleightholme Area: South Yorkshire (East) Responses identified: 2 / 1 View PDF

A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable individuals.

Date 23 Oct 2015

56-day deadline 14 Dec 2015

Responses identified 2 of 1

State Custody related deaths

Coroner's concerns

AI summary

A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable individuals.

View full coroner's concerns

i) The ACCT was closed by a person who had previous dealings with Samuel without reference to healthcare, the chaplaincy or a unit manager or any officer who had carried out an ACCT review.

ii) The Deputy Director was asked to consider whether only the person who is primarily responsible for a prisoner’s ACCT should be the one to close it.

Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 320844 | Fax 01302 364833

Responses

2 respondents

Serco Private Sector

30 Oct 2015 PDF

Action Taken

Policy changes have been made so that only a manager grade can close an ACCT, and ACCTs cannot be closed unless the case review comprises at least two people and all actions on the CAREMAP have been completed; HMP & YOI Doncaster will seek to move to a case management model during 2016 whereby a nominated case manager manages a case load so that continuity of care is improved. (AI summary)

View full response

Dear Mr Sleightholme Re: Samuel William Gale Deceased DOB: 13.08.1995 DOD: 17.05.2014 Further to your correspondence of 27 October 2015 and your report under Regulation 28 The concern raised relates to closure of the ACCT without reference to healthcare, chaplaincy or a unit manager or any officer who had carried out the review, and have been asked to consider whether only the person who is primarily responsible for a prisoner' s ACCT should be the one to close it have considered the matter further and made reference to Prison Service Instructions on the management of the ACCT and conclude our actions are as follows: a) Policy changes have been made since this incident s0 that only manager grade can close an ACCT. b) Case Managers will comprise of manager grades only. c) ACCT cannot be closed unless the case review comprises of at least two people and all the actions on the CAREMAP have been completed. d) It would be impractical to implement process whereby only the person who is primarily responsible for a prisoners ACCT should be the one to close it: Such action may leave a prisoner under a level of scrutiny and support that is not conducive to a prisoner $ ongoing wellbeing: OFFICIAL Berco Home Affalre; diskn of Serco Umlted: A company rglatered In England and Walae No. 242246 Regletored Olice; Serco House 16 Bartloy Wood Buslness Park; Bartiey Way; Hook; Hampshire, AC27 9UY Unltod Kingdom

OFFICIAL Staff sickness, annual leave and lost days also render this impractical. Notwithstanding this, HMP & YOI Doncaster will seek to move to a case management model during 2016 whereby a nominated case manager manages a case load so that continuity of care is improved resulting in case reviews completed by the same manager on a more frequent basis: The timing for completion of this objective is by June 2016.

NHS England NHS / Health Body

10 Nov 2015 PDF

Action Planned

NHS England is reviewing templates for first night screening and risk assessment as part of the deployment of a new Health & Justice Information System, with rollout expected from July 2016 to July 2017. (AI summary)

View full response

Dear Ms Sleightholme RE: Samuel William Gale_ (Deceased Further to your letter dated 27 October 2015 regarding the above named have read the report and your concerns relate to the embedding of mandatory risk assessments in the national procurement of a new SystmOne The new Health & Justice Information System will be a national system for the residential estate and as part of the deployment we are working with the Health and Social Care Information Centre and NHS England Clinical Reference Group to review a number of templates and first night screening and risk assessment is one of these templates. The timeline for the work is that from July 2016 NHS England will be undertaking the deployment and roll to all sites of the new system, with an expectation that the full functionality will be in place by July 2017. This will include the roll out of any new national templates_ hope this clarifies your outstanding issues and please do not hesitate to contact me should you require any further clarification:

Report sections

Investigation and inquest

On 27/05/2014 I commenced an investigation into the death of Samuel William Gale, 18 . The investigation concluded at the end of the inquest on 15 October 2015. The conclusion of the inquest was Open conclusion. The cause of death 1a Hanging

Circumstances of the death

Samuel Gale was received into custody at HMP Doncaster on 3rd May 2014. He was 18 years of age, a first time inmate who faced serious charges of rape. Furthermore, it was recognised by prior custody officers and healthcare nurses that he was very distressed at being barred from attending his father’s funeral by his mother and siblings who blamed him for his father’s suicide in February 2014. He had self-harmed and made an attempt at suicide recently and at times felt suicidal. He was immediately placed on an ACCT and half hourly observations were directed. On 16th May the ACCT was closed and he was found hanging the following day.

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Billy Wright Inquiry HMP Maghaberry lessons learned

Report details

Reference: 2015-0454
Date of report: 23 October 2015
Coroner: John Sleightholme
Coroner area: South Yorkshire (East)

Responses identified

Responses identified 2 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 14 Dec 2015.

Sent to

HMP and YOI Doncaster

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.