Alex Kelly

{OVER HAALEIS WQUESL ITQ THE DEATH ALEX KELLY RESPONSE_from_TOWER HAMLETS COUNCIL to the Jetter from the Coroner dated 28 December 2014 Introduction 1_ This is the response Tower Hamlets Council (hereinafter "The Council") to the Coroner's Regulation 28 report dated 28 December 2014 following the inquest into the death of Alex Kelly: 2_ As stated in the report Alex Kelly (AK) was a looked after child under the care of The Council from the age of 6. The Council undertook a detailed Serious Case Review following AK's death and as a result a number of actions have been taken to ensure that lessons are learned for the future_ 3 The Council provided formal evidence atythe inquest via a statement and live evidence from myself;, Interim Service Head, Children's Social Care, in relation to lessons learned by the Council 4_ This response sets out below the extracts from the Coroner's report and a response from the Council: This response only addresses the points that specifically relate to the Council: Case Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody: Difficulties in allocation were not escalated to senior management 5_ The Council agrees that it is not acceptable for a looked after child to be left without an allocated social worker for period of two months_ The circumstances at that time in 2011 (organisational change and the absence, due to ill health, of the previous allocated social worker) provided the context in which this occurred but that does not excuse the lack of active social work involvement
6. Children's Social Care Services in Tower Hamlets has a clear expectation that all children and young people looked after by the council will have an allocated social worker. The number of social workers in the teams providing this service been maintained despite a reduction in the number of looked after children and this has been reflected in smaller case loads Managers within the service are clear that ensuring that all looked after children have an allocated social worker is one of their primary responsibilities. QF from have

7_ The Children's Social Care Management Team receives a monthly report providing information about all children and young people receiving service This includes confirmation of the allocation of looked after children (and children subject to protection plan); if the performance report shows that any of these vulnerable children appears to be without an allocated worker, then the responsible senior manager is required to investigate this as matter of urgency. There have not been any unallocated looked after children over the course of last 3 years, other than the brief period in which are being transferred between social work staff / social work teams_ 8_ Since the completion of the organisational restructure in January 2012, Service and Team Managers have been reminded of the need to ensure that case transfer is undertaken in an efficient and timely manner and that there is always an identified key worker for each case_ 9 The Head of Service has written to all of the Independent Reviewing Officers to remind them of their responsibility to raise any concerns about case allocation and planning to Team and Service Managers and ultimately to the Head of Service via an escalation policy. This escalation policy is based upon the use of alerts to draw to the attention of first line middle and senior managers the failure to implement any part of the plan for looked after child, including allocation to social worker. The escalation policy was reviewed and updated in 2013 and has been used to highlight concerns about the lack of progress in the implementation of plans for some looked after children. Information Technology a) Social Workers did not transfer documentation; including emails; onto Framework in a timely manner or at all
10.Children's Social Care recording systems have become increasingly complex with the need to ensure that wide range of ance and regulation is adhered to, data captured and records maintained. There is a balance to be achieved between social work time spent in front of computer recording this information and direct contact with the children_ young people and families for whom a social worker is responsible as was pointed out by Professor Eileen Munro in her review of child protection service published in 2010.
11.The case recording system used in Tower Hamlets , Framework is acknowledged to be one of the more user friendly software systems available There is not an alternative available that would offer significant benefits to staff in terms of ease of use or the automation of routine tasks_ Managers and staff have developed and implemented changes to the processes within Framework to improve its ease of use_
12.The Council accepts that; in this instance, significant information was not recorded within Framework
1.. Social Work staff are trained at induction the they guidz

and reminded at regular intervals of the need to ensure that they properly maintain the records of the children and young people with whom are working:
13.The Council has reviewed the guidance issued to staff on recording and provided briefing sessions for staff to reinforce the Council's expectations that relevant information is recorded uploaded into Framework in timely manner First line managers are required to review case records on regular basis, through monthly case audits of the records and through exercising management over sight of the work being undertaken: A report demonstrating the extent to which managers are reviewing case files is provided to the Children's Social Care Management Team every month which shows the percentage of cases that have been reviewed by the relevant manager the previous month b) There was no system in place for ensuring that urgent electronic communications were flagged diverted when the recipient was absent from work
14.The Council accepts that there is need to ensure that there is mechanism to alert external agencies when a member of staff is absent and to provide an alternative contact within the council during such period of time
15.Managers and Social Work Staff have been reminded of the need to ensure that if are going to be absent from work, they must ensure that a message is placed on their email account to indicate when will return to work and who to contact in the event of an emergency. Reminders will be repeated every three months_
16.Unfortunately, it is more complicated to make similar arrangements for members of staff who are away from work unexpectedly, e.g. because of ill health. Some staff have access to their email accounts from home or via a mobile device and can add an "out of office message from home in the event of unexpected absence from work. However; not all staff have this facility and because access to the council's email system requires triple authentication together with requirement to treat all passwords confidentially, cannot arrange for somebody else to do this on their behalf. Managers have therefore been instructed that; in the event of the unexpected absence of a member of staff, they should request that an out of office message is added to the email account of the absent member of staff by the Council's information technology provider: This does not happen immediately and it can take up to week for the system to be amended. However, we have undertaken random audits of the email accounts of staff who are absent from work and will continue to do So in the future_ There has been an improvement in awareness of the need to ensure that the messages are in place and in managers requesting that systems are amended_ they during they they they

17.Colleagues in other agencies are aware that; in the event that urgent email correspondence does not receive timely response, then they should contact the manager of the member of staff concerned to ascertain why have not received response Managers in turn should be reviewing the work of social worker who is absent from work and making contingency plans in the event that absence continues beyond or two Custody Social Workers did not all appear to appreciate that their responsibilities as Corporate Parents included role in a looked after child's welfare whilst in custody:
18. The Council accepts that; on this occasion, Social Work staff did not always appreciate that their statutory responsibilities as Corporate Parents continued despite the fact that a young person was in custody In comparison to the overall numbers of looked after children relatively few receive custodial sentence and not all staff were familiar with this situation.
19.The Children's Social Service and the local Youth Offending Service have devised protocol setting out clearly the responsibilities of each service in the event that young person receives a custodial sentence which has been updated to take account of changes in the legislative framework_ The launch of the revised protocol provided an opportunity to remind Social Work staff that a custodial sentence does not remove their statutory responsibilities towards a looked after child although may not be able to exercise those responsibilities_
20.In addition , the implementation of the Legal Aid, Sentencing and Punishment of Offenders Act 2012 has meant that a larger group of young people become looked after as a consequence of custodial remands This has meant that Social Work staff now greater awareness and familiarity, through their to practice , of parallel responsibilities that the Council has towards young people who are both looked after and in custody Conclusion
21./ hope that the above addresses the concerns raised in the Coroner's report: The Council remains committed to learning lessons from untoward incidents and continually improving the care provided to the young people for whom we are responsible.

Dear Ms Harding, Re: Regulation 28 Report to Prevent Future Deaths (Inquest into the death of Alex Kelly, HMYOI Cookham Wood) am writing with reference to the above-mentioned report which you issued on 28th December 2014 under paragraph 7 , Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. read your report with great sadness. The death of Alex Kelly, aged 15,on 25th January 2012 is utterly tragic. Central and North West London NHS Foundation Trust (CNWL) commenced delivery of child and adolescent mental health services in HMYOI Cookham Wood in April 2014,yet the recommendations you have made are clearly relevant to our work and the work of our close partners HM Prison Service, NHS England and Oxleas NHS Foundation Trust Whilst your Regulation 28 report was not addressed to CNWL, as the incumbent provider of mental health services we feel duty-bound to provide you with a formal response to your health-related recommendations_
1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication CNWL's Health and Wellbeing (mental health) Team in HMYOI Cookham Wood includes a variety of mental health professionals, including a forensic child and adolescent psychiatrist; clinical psychologist, art therapist and nurses_ The team Trust Headquarters, Stephenson House, 75 Hampstead Road, London NW1 2PL Telephone: 020 3214 5700 Fax: 020 3214 5701 WW cnwLnhs uk Wellbeing for life MPAESiCR "`(' 0 OOTCIuan PARTNERSHIP London Milton Keynes Kent Surrey Hampshire

assesses and treats a wide range of mental health conditions and personality and behavioural issues that young people present with, including ADHD, conduct disorder, emerging personality difficulties as well as those who have been perpetrators and or victims of sexual abuse_ This range of service provision was not commissioned or available at the time of Alex's death_ The new service is well embedded in local custody management programmes and governance systems, and the increased availability of staff has improved partnership working and information exchange amongst the many professionals working in HMYOI Cookham Wood. Our healthcare staff are acutely aware that non-compliance with certain prescribed medications may indicate that a young person's mental state has deteriorated, or that it may deteriorate in future This can result in planned or impulsive self-harm or suicidal acts_ Healthcare staff are therefore required to share this knowledge with other partners for patients receiving psychotropic and other potentially harmful medications_ All of our staff have completed information governance training and have robust policies to refer to, and assist them to make the appropriate decision about when and how to share important healthcare information with other parties, both inside, and outside HMYOI Cookham Wood. All clinical information is documented on the IT program Systm1, which is shared with other healthcare providers working within the establishment namely, Oxleas NHS Foundation Trust. Information that is shared with other parties on 'need to know' basis is conveyed in person and recorded on P-NOMIS (the IT program used by HM Prison Service staff) , Wing / Unit Officer's observation books and in ACCT folders_ When our staff are involved in the care of a young person about whom there are specific concerns will use existing methods of communication within the prison to ensure are up to date and engaged in two-way sharing of information. Of particular relevance is the Safer Regime meeting at HMYOl Cookham Wood where complex cases are discussed by all involved agencies. A senior member of our team attends this meeting: In relation to the specific concern of medication non-compliance, our team have a joint handover with Oxlea's primary care team four per week where such issues are raised: They are also alerted via an electronic "task' on Systm1. tasks are discussed in daily handover meetings which would flag the need for review by our psychiatrists. If there are concerns on review; these would be shared with officer staff through the handover book or ACCT and Team Around the Child (TAC) processes if appropriate. 2 Medication Management a) Medication was found stockpiled in the young person's cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken: b) failure to take medication was not sufficiently flagged for healthcare prison staff to deal with the issue. for, they they days Any Any

Oxleas NHS Foundation Trust have responded in detail on this point; as it is their staff who administer prescribed medications in HMYOI Cookham Wood. However, it is our responsibility to provide urgent medical and psychological review of young people who we are informed are non-compliant with prescribed medication, as could a) 'stockpiling' medication with which to overdose, b) 'trading' it as an abusable commodity, c) may feel that the medication is simply not helping them. 3 Recording of Information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One: As described above, all clinical contact by the Health and Wellbeing (mental health) Team is recorded on Systm1 . Office space and access to IT has improved. In August 2014, the new team relocated to recently refurbished room which has four new computers: All staff members have a direct line manager with supervisory responsibility Line managers are responsible for checking staff entries made on Systm1 so that accurate and timely entries are made; which demonstrate appropriate care planning, risk management and information sharing: AIl new team members have received training to use Systm1, and an annual record keeping audit will serve to monitor documentation standards_ sincerely hope that our response wholly and adequately addresses the recommendations that are relevant to our service_

Dear Ms Harding Re: Inquest Alex Kelly Regulation Report to prevent further deaths Thank you for your letter and enclosed report dated the 30 December 2014,relating to your findings of the review into the death of Alex Kelly on the 25 January 2012. As you have identified within your report, Oxleas NHS Foundation Trust was not the provider of healthcare at the time of this young man'$ death: We began to provide primary care services in HMPYOI Cookham Wood in April 2014. On the same date Central and North West London (CNWL) NHS Foundation Trust were awarded the contract to provide the Child and Adolescent Mental Health Service to Cookham Wood. am therefore copying your report and this response to the chief executive of CNWL. would like to begin by confirming that every child who arrives at Cookham Wood is assessed by our staff using a Comprehensive Health Assessment Tool commonly known as the CHAT Tool. This is an evidence based assessment tool addressing physical health, substance misuse, and mental health issues. If indicated by this assessment, a worker is allocated to the child with responsibility for care planning and ensuring the young person's needs are met AIl staff have been trained in the use of CHAT and we have implemented a series of standards to ensure that we monitor its use and implementation. All new admissions to the prison are offered these assessments and the take up rate is over 98%. Those who initially refuse are approached to be assessed at a later date. will now address the specific issues relating to healthcare listed in your report Sharing of information: Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication. MINDFUL EMPLOYER D15ABL*9 28, key ABOUr 0 1

Healthcare staff are aware of the need to inform all those involved in the management of a young person about their compliance with medication and to record such issues within the medical record and other prison documentation ACCT, NOMIS and observation book All healthcare staff complete mandatory trust and HMPS Information Governance training, which also includes information sharing guidelines. The process is embedded in established clinical and safer custody forums Medication Management Medication was found stockpiled in the young person's cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken: The majority of medications are now dispensed under supervised conditions and, where risk assessment deems it appropriate, in liquid form. Young people are asked to demonstrate the medication has been taken by opening their mouths. Staff will only then record that the medication has been administered using the electronic clinical record (SystmOne): If there are concerns about the possible diversion or failure to ingest medication, this is recorded and the relevant persons notified. This includes completing a security report and informing wing staff and other clinicians, such as CAMHS_ Any failure to take medication was not sufficiently flagged for healthcare prison staff to deal with the issue. Information is shared and recorded as detailed above. A young person's failure to take medication due to refusal or non-attendance generates a referral to the specialty which initiated the treatment: in turn, review and update the individual' s care plan a5 well as providing further advice. hope this response adequately covers the points of concern you identified. Yours sincerelv Stephen Fitn Chief Executive Stephen firn @oxleas nhsuk Cc: Director Forensic & Prison Services ICE, CNWL MINDFUL EMPLOYER D1SABLS9 wing They, ABOUr 0 People

Dear Ms Harding Requlation 28 Report_Response by Medway Council (Youth Offending Team) in respect of the death of Alex Kelly Please find enclosed the response from the Medway Youth Offending Team to your concerns as outlined in your Report to Prevent Future Deaths, dated 28th December 2014_ Please note item 3, concerning the Caseworker based at Cookham Wood has been drafted in consultation with the Governor at Cookham Wood, as the staff there who are seconded by Medway Youth Offending Team are operationally managed by the Prison Service, but remain the responsibility of the Medway Youth Offending Team: If can be of any further assistance, or if you require any clarification in respect of this response please do get in contact.

Dear Ms Harding Thank you for your Regulation 28 Report to Prevent Future Deaths addressed, amongst others, to the Secretary of State for Justice and the Governor of HMYOI Cookham Wood, concerning the inquest into the death of Alex Kelly on 25 January
2012. Your report has been passed to Equality Rights and Decency (ERD) Group in the National Offender Management Service (NOMS) , as we have responsibility for policy on suicide prevention and self-harm management, and for sharing learning from deaths in custody. am responding on behalf of the Secretary of State for Justice; NOMS and HM Young Offenders Institution (YOl) Cookham Wood. am grateful to you for allowing us an extension to enable us to provide comprehensive response to the concerns raised in your report You will be aware that the death of Alex Kelly was one of three tragic deaths of young people that occurred in 2011-2012, and that in response to these deaths range of actions were taken to improve the care and management of young people This letter will focus on the actions that are relevant to your concerns, but before doing so it may be helpful to provide you with some information about broader programme of reform currently being undertaken in the NOMS Young People's Estate (YPE): This touches on wide range of operational policies and practices; and will see fundamental changes made to the way in which the core day is structured in the YPE in order to support delivery of an enhanced regime that will provide young people with increased access to education and twice as much time in the open air each day_ The reforms include the introduction of standardised casework model in all establishments within the YPE addressing the inconsistencies in the current provision of this key service. This multi-disciplinary model will ensure that young people are better supported their time in custody and that plans for their resettlement into the community or transition into adult custodial services are developed and implemented more effectively: Our caseworkers will be at the heart of the model, co-ordinating the contributions of all internal and external stakeholders to the plans for a young person's time in custody and the preparation for their transition or resettlement, Agreements will be put in place to emphasise the obligation on all involved to work proactively together in order to secure the specialist input required for each individual young person Casework managers will have particularly important role to play in overseeing this function of the model, making frequent management checks of the information recorded by casework teams and addressing any issues that arise. during

will now proceed to address the concerns in your report that were directed to the Secretary of State and the Governor of HMYOI Cookham Wood: The first of your concerns addressed to the Secretary of State is that children in custody may not have had a forensic psychiatric assessment am aware that in response to your report Oxleas NHS Foundation Trust (which, as you are aware, was not the provider of healthcare services at the time of Mr Kelly's death) explained that the Comprehensive Health Assessment Tool (CHAT) is in use for all new admissions at HMYOI Cookham Wood. The CHAT is a validated screening and assessment tool for use with children aged 10-18 held in secure settings on youth justice or welfare grounds: The CHAT has been rolled out across the YPE and has five parts: Reception screen 2 Physical Health 3 Substance Misuse Mental health
5. Neuro-disability Part 1 is delivered by healthcare within 2 hours of reception: This ensures that areas of concern are identified immediately and measures required to ensure safety are taken promptly. This may include one or more of the further assessments, which will all be undertaken within 10 days in any event: All healthcare staff at HMYOI Cookham Wood are trained in the use of the CHAT, and a set of standards is in place to monitor the effectiveness of its use_ All young people admitted to the establishment are offered these assessments, and, as the response from Oxleas NHS Trust indicated, the take up is currently over 98%_ For the small number of young people who decline, arrangements are in place for staff to discuss with them their reasons for doing so and to encourage them to undertake the assessment at a later date Following the completion of the assessment each young person will be assigned a named nurse_ The nurses are supported by Support, Time and Recovery workers and Healthcare Assistants_ Issues identified during the assessment process are addressed through a referral to nurse or GP, or to a relevant specialist intervention within or beyond the prison You may be aware of the wider context of the 2011 commitment by the Secretaries of State for Justice and Health to develop Liaison and Diversion services across the country: The national Liaison and Diversion Programme is being taken forward in partnership by the Department of Health, Ministry of Justice, the Home Office , NHS England, Public Health England, and the various relevant criminal justice agencies. Liaison and Diversion services will include services in the following settings: police engagement with adults children and young people in the community; police custody suites and voluntary attendances at police stations; magistrates" and youth courts and the Crown Court; the National Probation Service; and youth offending teams_ Liaison and Diversion services aim to identify, assess and refer people with mental health, learning disability substance misuse and social vulnerabilities into treatment or support services, when first come into contact with the police and criminal justice system (CJS): When person is assessed as having single or multiple vulnerabilities, be referred to the appropriate treatment or support service and an appropriate package of care andlor support will be instigated Accurate timely information on the person will be shared with police and the courts to ensure that any charging; sentencing or disposal decisions are based upon an authoritative they they will

assessment of their mental health, any learning disability and whether they have substance misuse issue_ Liaison and Diversion services support the most appropriate outcome for those individuals For many this contact with criminal justice agencies will be the first time will have been assessed and diagnosed. E25 million has been invested during 2014-15 in police stations and courts in ten areas of the country to fund Liaison and Diversion professionals in police stations and courts; During this trial period, schemes have been developing range of Liaison and Diversion activities such as improving youth provision towards an all age service, providing identification, assessment and referral services at all times to reflect need and developing partnerships between judiciary, police and mental health agencies From April 2015, these services be extended to a further 12 areas of the country, bringing coverage to over 50% of the population of England. Almost 12,000 adults and over 1,500 children and young people have engaged with Liaison and Diversion trial services in the 9 months to 31st December 2014. The expanded trial sites will continue to run for 12 months and, if successful following a business case to be submitted to the Treasury later this year, the model will be extended to all areas, aiming to cover the population of England by 2017. Addressing vulnerabilities is expected to lead to greater efficiency in the CJS, and improved criminal justice outcomes for vulnerable individuals The CJS itself will benefit from the provision of information at an earlier which could reduce the duration of detention where appropriate disposals are an option; inform charging and disposal decisions by the police and CPS; assist YOTs with assessments of health needs to divert young people away from the CJS; and ensure earlier provision of reports to the courts system: These reports to court will contain relevant and informed health related information and offer proposals which take account of the particular needs of the individual concerned (for example, a recommendation for community sentence involving Mental Health Treatment Requirement). Where Liaison and Diversion interventions are successful and the particular needs of an individual are identified and addressed it is anticipated that their treatment will improve their health which could contribute to a reduction in re-offending: Vulnerable individuals should benefit from better-informed charging, sentencing and appropriate disposal decisions by the police, Youth Offending Teams (YOTs), the Crown Prosecution Service (CPS) , magistrates' and youth courts and the Crown Court: Vulnerable individuals would also be enabled to better engage in proceedings, through the provision of reasonable adjustments . The core set of operational components are: Early_Intervention by ensuring that an individuals' (adult and youths) health and social care needs are identified and assessed as early as possible following contact with police under suspicion of committing an offence. Information_Sharing making information on an individuals' health and social care needs available at all subsequent stages of the CJS, including police custody, the CPS, courts, YOTs and probation_ This will ensure that decision makers in the can make informed decisions about justice disposals; and improve timeliness and efficiency of the justice process. they will stage, key

Appropriate_Referrals ensuring that where health and social care needs are identified an individual is referred to appropriate treatment services Referrals Followed_Up ensuring that where referrals are made, are followed up both assertively, and flexibly, to ensure engagement with services_ The second concern that you have addressed to the Secretary of State is the apparent conflict between the Assessment, Care in Custody and Teamwork (ACCT) process and disciplinary procedures , and this is addressed in the section on ACCT below. The first concern that you have addressed to the Governor of HMYOl Cookham Wood is about communication outside_ agencies The planned improvements to the management of casework described above are of relevance here_ and NOMS believes that will ensure more effective information sharing and better integrated care and management of young people: Prison Service Instruction (PSI) 08/2012 Care and Management of Young People sets out a requirement for each under 18 YOl to have an information sharing policy to ensure that relevant information is shared with professionals, parents or carers_ and others, at appropriate intervals_ HMYOI Cookham Wood has policy, and the Governor is currently conducting the annual review that is undertaken to ensure that it always reflects current legislation and best practice_ It mandates that information is shared with families and other appropriate bodies or persons (for example, the YOT), on each of the following occasions: On first reception; At the conclusion of the initial sentence planning process; After each important review; On transfer to another establishment; Prior to release, within the purpose of encouraging their contribution; Where force has been used on the young person; Where a child protection referral is made; and Following other significant events such as illness, victimisation or self harm. The policy also states that information about a young person is not shared where to do so would that young person or others at increased risk of significant harm, or an adult at risk of serious harm, or ifit would undermine the security ofthe establishment or the prevention or detection of a serious crime_ PSI 08/2012 also makes it clear that any concerns about prisoners raised by visitors or others must be passed to relevant staff_ AI NOMS staff are required to complete annual information assurance training which covers the principles of data protection and information sharing, including the importance of sharing risk-relevant information: Additionally, all staff in YOls have been provided the Department of Health's best practice guidance on when to share information with other agencies in the youth justice system, and receive local safeguarding training which highlights the need to share information pertinent to risk. PSI 64/2011 provides detailed guidance on information sharing with respect to safer custody concerns It sets out the procedures that staff should follow to ensure that reliable and accurate information is shared between relevant agencies to inform appropriate decision making: they with they such put

The second concern that you have addressed to the Governor of HMYOI Cookham Wood relates to the local implementation of the ACCT process All staff at HMYOI Cookham Wood who are in direct contact with young people receive the Introduction to Safer Custody training as part of prison officer level training or during their induction: This is an introductory course that gives general introduction to safer custody, including suicide prevention, self-harm management and violence, and the different roles and processes related to it ACCT refresher training continues to be delivered to both directly and non-directly employed staff as part of the wider ongoing training programme. Most recently, ACCT case manager training has been delivered to all Supervising Officers because it is their responsibility to undertake this role_ These training courses coverall aspects of the ACCT process, including the requirements to record all relevant and significant information: As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice , Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOls in 2013. In January 2015 a further letter to the Governors of under 18 YOls set out a number of actions, including a requirement to ensure that quality_assurance process is in place to identify and rectify any deficiencies in the ACCT process As a result a more rigorous quality assurance process has been introduced at HMYOI Cookham Wood;, and this includes individual feedback to case managers. These quality assurance checks include ensuring that all appropriate information has been recorded and that due consideration has been given to the involvement of relevant outside agencies in the care of the young person at risk In your report you also expressed your concern about information not being shared with the safer prisons meeting: New terms of reference have been developed for this meeting and a broader range of professionals now attend the safer regimes meeting; including practitioners from physical and mental healthcare providers, the psychology department, the substance misuse service , the education provider and the chaplaincy; as well as representatives from the residential, safeguarding and security functions within the establishment The meetings are chaired by the Head of Residence who is responsible for ensuring that all members have all the information that require, as well as agreeing the minutes of the meetings before they are published. The third concern that you have addressed to the Governor of HMYOI Cookham Wood relates to what you describe as a conflict between regimes, in the sense that the ACCT process and behaviour improvement plan were not sufficiently joined up with the adjudications process_ A staff notice was published at Cookham Wood in November 2014 to remind staff of the requirement to take ACCT plans to adjudications to ensure that adjudicators are aware that young person placed on report is being supported by the ACCT process. This allows adjudicators to take into account any issues raised in the care map Or triggers for self-harm in order to ensure that adjudication awards do not increase the risk of further self-harm. entry they

The behaviour improvement plans in use at HMYOI Cookham Wood have been revised and are reviewed at the safer regimes meeting described above to ensure that there is no conflict between the plan developed to support a young person and the use of the adjudications process. The planned improvements to the management of casework described above ensure that all assessments and individual department plans are co-ordinated. There will be a single sentence plan that is reviewed in line with the requirements set out in the YJB's National Standards as a minimum, and more often where necessary and this will ensure that the various different processes, such as ACCT and adjudications, complement each other The fourth concern that you have addressed to the Governor of HMYOI Cookham Wood relate to early release All cases in which early release is a possibility are subject to a formal review: This is conducted by Board consisting of the young person's establishment-based caseworker; the YOT casework manager and the custodial manager; and is informed by a contribution from the young person's homelexternal YOT worker: The Board considers the young person's custodial behaviour, progress against their training plan, their resettlement plan and the recommendation of their external YOT, as well as any security information: The Board makes recommendation which is considered by a senior manager within the establishment who makes the decision on whether or not early release is approved: The fifth concern that you have addressed to the Governor of HMYOI Cookham Wood concerns_cell entry: Night operating procedures state that under normal circumstances the authority to unlock & cell will be given by the duty Night Orderly Officer and requires the presence of three operational members of staff. However where there is, or appears to be_ an immediate threat to life_ cells may be opened by a single member of staff. For this reason, night patrol staff carry a sealed pouch containing a cell key to allow them to unlock cells in an emergency: All staff performing night patrol duties at HMP Cookham Wood are issued with pack explaining this and other relevant procedures, and are briefed to this effect at the start of their shift The responses from Oxleas NHS Trust and the Central and North West London (CNWL) NHS Foundation Trust have responded in detail to the concerns that you addressed to healthcare at HMYOI Cookham Wood, but would like to add one point with regard to the sharing of information In addition to the requirement for healthcare staff to complete mandatory information governance training that covers the information sharing guidelines, can confirm that as an additional safeguard an information sharing protocol between all relevant agencies providing services at HMYOl Cookham Wood is being formulated and we anticipate that this be signed in the near future hope that this letter has been helpful in explaining the action that is being taken to address your concerns and provides reassurance that they are taken very seriously by staff and management at HMYOI Cookham Wood and across NOMS: Youresincerel cnris Barnei-page will will being