Geraldine Kilborn

Coroner's concerns

AI summary

There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied on potentially misleading face-to-face assessments without reviewing documentation.

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In the circumstances it is my statutory duty t0 report t0 you: (1 was a clear breakdown in sharing of information known to the mental health Way, aged hung Jury day wing wing Jury entry: The There team with other members of some ACCT reviews: Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends: Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that both attend relevant ACCT reviews and their opinions are given sufficient weight: is noted that mental health nurses never chair such ACCT reviews as case manager and this case has revealed that even in attendance, their views might not be given sufficient weight: (2) Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees who might know the prisoner and upon their face to face assessment of the prisoner at the time. In this case , some ACCT review members had limited to experience of the deceased, whose temperament and presentation could change "like a light switch" and therefore face to face presentation could well be misleading: Thus in cases where the ACCT review was dealing with a particularly complex and challenging prisoner and where an enhanced review was called tor, it would seem appropriate for further consideration to be given to the question of review panel membership generally as well as, as above, mental health input in particular.

Responses

3 respondents

HM Prison and Probation Service Central Government

10 Dec 2014 PDF

Action Taken

An amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team. (AI summary)

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Dear Mr Tweddle Thank you for your Regulation 28 report dated 10 December 2014, concerning the recent inquest into the death of Geraldine Liege Kilborn on 2 December 2013 at HMPRYOI Low Newton: This response been formulated In consultation with the Governor of HMPE YOI Low Newton: am aware that your report was also sent to Tees, Esk, Wear Valley NHS Foundation Trust and Care UK who will be repling separately: Your letter raises two concerns, and will address these In turn: Tebreakdown gt Infqmatlon sharng between mentaLhealth saftand the_otherstaff Involved n AccTrevews Prison Service Instructlon (PSI) 64/2011 Safer Custody describes the importance of information sharing and is very clear that healthcare staff have a duty to pass on information that involves Issues of patient safety, vulnerability or Immedlate rlsk to self or others to relevant staff: This applies in any situatlon In which the prisoner's safety Is compromised, even if are unable or unwllling to give consent: This Is primarily a matter for the healthcare provider, but | can Inform you that a amended arrangement has been put in place to faclitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend: Effective mental health Input is now ensured in all cases in which a prisoner has mental health issues: for prisoners who are located in the healthcare centre, & band 5 nurse Is allocated as case manager; &d for prisoners located elsewhere a member of mental health team attends all case reviews Briefing sessions have been introduced to facilitate the sharing of Information between prison staff ad the mental health team, ensuring that all staff are able to make meaningful contribution to the decision about the level of rlsk: Sase revlew: PSI 64/2011 recognlses that the ACCT process will operate more effectively If there is contlnuity in the attendance of staff from relevant departmentslservices at case reviews Whilst not stated explkcitly in the policy; t is clear from the list of mandatory actkns for the FEB 2045 has duty they the

review team that those present must make themselves famillar with the Information contained In the ACCT document At HMP&Yol Low Newton the same staff attend ACCT reviews wherever possible_ All relevant information; including developments slnce the last revlew, Is discussed at the case review: This Includes any information from the SystmOne record that It Is appropriate for healthcare staff to share: In complex cases the enhanced case revlew team involves all relevant disciplines and Is chaired by a higher level operational manager than a typical ACCT case review, usually the head of safer custody: In response to your report; all case managers case review chairs have been reminded of the need to familiarise themselves with all relevant informatlon, including the records of previous reviews and recent entrles in the ACCT document; before conducting a case review: hope this provides YoU with assurance that the matters of concern that you have identified have been fully addressed_

Care UK Private Sector

28 Jan 2015 PDF

Action Planned

From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model. Daily reviews will be undertaken by a member of the mental health team, as on any patient allocated for, Healthcare with mental health issues: In addition all complex ACCT cases will be discussed at morning handover to increase staff awareness. A registered nurse with previous knowledge of the patient will be in attendance at an ACCT review. (AI summary)

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Dear Sir, RE: Theinquest touching the death of Geraldine Liege Kilborn Deceased Response to Regulation 28 Report to Prevent Future_ Deaths am writing in reply to you email dated 10lh December 2014 containing the Regulation 28 Report to Prevent Future Deaths ("PFD Report") following the conclusion of the inquest touching the death of Geraldine Liege Kilborn Deceased which was heard before yoU, sitting with a at the Coroners Court; Crook commencing on 3r December and concluding on 5 December 2014. In hearing evidence at Kilborn's inquest you have identified matters of concem as follows:
1. There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends: Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight: It is noted that the mental health nurses never chair such ACCT reviews as case manager and this case has revealed that even in attendance, their views might not be given sufficient weight: 2 Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied upon input of other attendees who might know the prisoner and upon their face to face assessment of the prisoner at the Care UK Connaught House, 850 The Crescent, Colchester Business Park, Colchester; Essex CO4 908 T01206 752552 F 0870 3363914

Box jury Ms they

time: In this case, some ACCT review members had limited day to experience of the deceased, whose temperament and presentation could change "like light switch" and therefore face to face presentation could well be misleading: Thus in cases where ACCT review was called it would seem appropriate for further consideration to be given to the question of review panel membership generally as well as, as above, mental health input in particular: Response: At the time of Ms Kilborn's death, the provision for mental health services delivered by Tees Esk and Wear valley NHS Trust covered Monday to Friday 9.OOam to 5.0Opm with on-call provision over the weekend: You heard evidence that the on-call facility was accessed by staff;, including the first weekend Ms Kilborn was at HMP Low Newton: From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model The National Health Service Commissioning Board has procured seven services GP Services including Pharmacy, Dental; Optometry,_Community Care, Non-Clinical Substance Misuse, Mental Health and Support Services: The new providers are to work collaboratively in defining a community focused approach to which health care and substance misuse services will interface . The new providers will continue to work very closely with key stake holders and prison governors to map out pathways of care Governance structures will promote an improved patient safety culture. Better communication is a requirement between all stakeholders. Daily reviews willbe undertaken by a member of the mental health team, as on any patient allocated Healthcare with mental health issues: In addition all complex ACCT cases will be discussed at moming handover to increase staff awareness. A registered nurse with previous knowledge of the patient will be in attendance at an ACCT review: In addition Mental Health staff are given access to the case review to give them an opportunity to schedule or prepare for any upcoming reviews. If a mutual convenient time cannot be accommodated a written or verbal input will be supplied by the Mental Health team which will be appropriately documented on the case review notes. As head of healthcare, attend the Governors meeting each moring and pertinent information is handed to the mental health team relating to individual patients: With regard to the sharing of information from SystmOne, medical confidentiality is ensured and information is shared with the consent of the patient: All staff are reminded of the importance of reviewing previous entries in the ACCT document: If you require any further information , please do not hesitate to contact me:

Tess Esk Wear Valleys NHS Trust NHS / Health Body

30 Jan 2015 PDF

Action Taken

TEWV has already made changes to the availability of Mental Health Team staff over the weekend. Staff are on duty between 9.30 am - 1230pm Saturday and Sunday, with a priority role to ensure that the relevant ACCT reviews are attended and that those women in crisis are offered support. Staff were reminded to read all the relevant information in the ACCT document and on System One notes. (AI summary)

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Dear Mr. Tweddle, Geraldlne Llege Kllborn deceased HMP Low Newton, Durham thank you for your letter dated 8 December 2014, enclosing a Regulation 28 report following the inquest into the death of Ms Liege Kilbom in HMP , Low Newton: The Trust is always keen to leam lessons and take all possible steps to prevent such deaths in the future The Trust does reflect on practices and procedures and has explored the systems in place at the time of the death of Ms Liege Kilbom -those systems have and will continue to be improved. The coronial feedback assists in that improvement process:
1. There was a breakdown In sharlng of Informatlon known to the Mental Health Team; wlth other members of the ACCT revlew; It Is vltal that In an appropriate case where a prisoner Is on an ACCT and has had substantlal mentai heaith Input that members of the Mental Health Team attend the relevant ACCT revlews and thelr opinlons are glven suffilclent welght: The issue you have highlighted is appreciated. It is vital that all parties involved in the care of a prisoner communicate well and have the opportunity to contribute to care planning: This is particularly relevant with prisoners who are suffering from mental health problems. Regarding availability of staff; TEWV have already made changes to the availability of the Mental Health Team staff over the weekend . Staff are on duty between 9.30 am 1230pm Saturday and Sunday, with a priority role to ensure that the relevant ACCT reviews are attended and that those women in crisis are offered support The ACCT Case Manager would also have access to an on-call Mental Health Manager: This INVESTORS IN PEOPLE Way FEB 2015

ensures that they would be able to provide a meaningful contribution to any ACCT review taking place, even on a weekend We have also completed the following action to ensure proper and timely communication between prison wing staff and Mental Health Team members the Mental Health Team Manager attends both the daily healthcare and Goverors moming meeting to ensure pertinent issues are discussed. A deputy will also attend the healthcare meeting if the MHT manager is not available e.g: on leave Since the death of Ms Kilborn the use of multi-disciplinary meetings has increased for those prisoners with complex care and risk needs. This is a proactive approach as, through the multi-disciplinary discussion, all issues can be addressed and understood, problems can be appropriately debated and consensus decisions reached This therefore enables the Mental Health Team to contribute appropriately to the ACCT process. 2 Wltnesses conflrmed that they often dld not read much of the ACCT document to the ACCT revlew and relled more upon the Input of the other attendees who mlght know the prlsoner and upon the face to face assessment of the prlsoner at the tlme: This is a very helpful observation. We agree that both the interview and the past infommation are important in making any decisions about a prisoners care plan. This relevant point was discussed at our clinical govemance meeting and stafif = meetings within the Mental Health Team: It is also part of the ACCT training delivered to all the staff working in the Mental Health Team Staff were reminded to read all the relevant information in the ACCT document and on System One notes_ In complex cases, we endeavour to provide consistent attendance to the ACCT reviews firom the Mental Health Team in the fomm of an identified named nurse, who is well informed about the prisoner: If that is not possible, we will ensure that the Mental Health Team member attending the ACCT review would have detailed knowledge about the prisoners presentation and mental health difficulties In cases where we are unable to attend we would make sure that the relevant information is shared with the ACCT team members making the necessary decisions The Mental Health Team access to the Safer Custody electronic and on daily basis planned ACCT reviews are diarised accordingly on System One_ TEWV has been awarded a new contract for the provision of mental health services into the local prisons and this will be in full service from 1 April 2015. The curent arrangements for the interface with prison staff is therefore under review and we shall fully incorporate all the findings from the inquest into any new arrangements.

Report sections

Investigation and inquest

On 3" December 2013 commenced an investigation into the death of Geraldine Liege Kilborn 37 years. The investigation concluded at the end of the inquest on 5th December 2014. The Jury could not determine the Deceased's intention when she herself. The concluded that following an ACCT review, the deceased was not appropriately located at the time of her death and that she would not have ended her life when she did, irrespective of her location

Circumstances of the death

Immediately upon entry into HMP Low Newton, the reception screen nurse deemed the deceased to be of high risk of self-harm and advocated a constant watch: Over the next 22 days prior to her death the deceased self-harmed repeatedly with many of the attempts being deemed by staff as being genuine attempts t0 take her own Iife: There were a series f ACCT reviews. For a time she was on constant observations, on normal location, in healthcare safer cell and healthcare normal cell: One ACCT review had no mental health staff input when such staff had asked to be present and somewhat incredulously, in evidence the ACCT case manager stated that he did not know that mental health care staff were available to attend on the in question: At the time of her death mental health care staff did not work weekends and at two critical ACCT reviews, there was no mental health input into the reviews_ Several mental health witnesses described tensions between mental health and staff , one such witness calling staff "dinosaurs' Senior key members of the last two ACCT reviews were unaware of the detailed entry made in system one notes by a Consultant Psychiatrist and did not take her views into account: On one of these two key reviews, which was attended by a senior general nurse, she did not share with the other review team members the knowledge that she had of the said system one Consultant Psychiatrist The was critical of the Prison's care of the deceased:.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action. your RESPONSE You are under a to respond to this report within 58 days of the date of this report, namely by 4l February 2015. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed:

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