Satheeskumar Mahatheaven

Dear Ms Hassell, Thank you for your Regulation 28 Reports of 19 September 2014 addressed to the Governor of HMP Pentonville and the Director of HMP Thameside, following the recent inquest into the death of Satheeskumar Mahathevan at HMP Pentonville on 20 April 2013 Your reports have been passed to Equality, Rights and Decency Group in the National Offender Management Service (NOMS), as we have the policy responsibility for suicide prevention and self-harm management; and for sharing learning from deaths in custody. am responding on behalf of the Governor of HMP Pentonville and the Director of HMP Thameside_ have liaised with staff in the establishments, including the healthcare providers_ and the healthcare commissioners, NHS England; in the preparation of this response_ The concerns raised in your report relate to the narrative determination made by the jury, which refers to failures in relation to information sharing and multi-agency communication procedures and inadequate training for staff. The specific issues in each of these areas are not identified, sO have considered each element relevant to the case_ Information sharing and multi-agency communication procedures There appear to be three issues that arise in this area; the use of risk information sent from the court to the prison, the communication of risk information between prisons, and requesting the community health records for use by the prison healthcare provider Local policies are now in place at HMP Pentonville and HMP Thameside to ensure that information is shared appropriately and that there is effective communication between prison staff and the healthcare provider. At both prisons, staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, including information received court, and of the factors that they should consider when assessing risk and sharing information between agencies At HMP Pentonville healthcare staff in reception now have access to all the relevant documents that arrive with the prisoner from court. This will include the prisoner escort record, core record, self harm warning form, custody record from police, andlor F2050 which contains the prisoner's warrant. The procedure is that on the arrival of a new prisoner the supervising officer on the reception desk checks the accompanying documentation. If any information regarding the prisoner's physical or mental health is identified this will be handed to the healthcare staff. The prisoner's file is then passed to staff on the induction wing who conduct a further check of the documentation, providing a second opportunity for relevant information to be found should it have been missed initially. This process is supplemented with a verbal handover from escort staff to reception staff in cases in which are aware of relevant risk information: from they

At HMP Thameside prison and healthcare staff work tdgether at the same counter: A new form has been designed specifically to ensure that all relevant information, including that received from the court; is communicated between the two groups of staff. On arrival at each prison, prisoners are requested to sign an "information sharing" form, which provides consent for necessary information to be shared as required, so ensuring continuity of care between establishments_ Both prisons currently use electronic medical records (SystmOne) and on receipt of a prisoner on transfer the healthcare staff in reception read alll relevant information on this system to ensure that are fully aware of their health needs Where there are concerns with prisoner's well-being, the sending prison contacts the feceiving prison to ensure that there is verbal handover in addition to immediate access to the kclinical records_ Community GP records are now routinely requested) in all cases in which there are health concerns. All attempts to contact GPs and other relevant agencies are clearly documented on the SystmOne electronic record. am informed by colleagues in NHS England that in response to this recommendation have added checks on the induction and communication policies and procedures to their annual audit process for healthcare providers. The findings ftom the next audit will be considered by healthcare commissioners in January 2015 and actipn will be taken to identify any issues identified Training for staff Prison Service Instruction 64/2011 requires all staff Iwho have contact with prisoners to be trained in the 'Introduction to Safer Custody' course, and there is more detailed training for staff in specific roles such as ACCT assessor and case manager. Prisons keep training needs under review and provide refresher training as required AIl new healthcare staff are shown how to use the SystmOne electronic record system correctly, and must be confident in using the system before being allowed access without supervision: AII healthcare staff at HMP Pentonville are also being trained in the use of PNOMIS to record prisoner information and made aware of how to obtain community records In December 2014 HMP Pentonville will be issuing revised guidance to all staff to ensure that appropriate codes are used in the event of a medical lemergency. Communications room staff will also receive revised instructions to ensure that an ambulance is called immediately on the relevant code used: hope this provides assurance that the matters of concern that you have raised have been addressed and that NOMS continues to make strenkous efforts to improve its systems and processes in these important areas: Yours cincerelv NOMS Equality, Rights and Decency Group they they being