HM Prison and Probation Service
Central Government
Action Planned
NOMS and NHSE will give further consideration to the extent to which screening processes should identify tobacco dependence and potential withdrawal issues. ACCT refresher training will reinforce that prisoners subject to ACCT procedures should be located in segregation units only in exceptional circumstances. (AI summary)
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Dear Dr Harris Thank You for your Regulation 28 report addressed to the National Offender Management Service (NOMS), NHS England (NHSE), and the Governor of HMP Belmarsh: Equality, Rights and Decency Group responds to all Regulation 28 correspondence as We have the policy responsibility for suicide prevention and self-harm management, and for sharing learning from deaths in custody: Please accept this a5 a response from NOMS (including HMP Belmarsh) and NHSE, who has been consulted about this response: You identified a number of issues in your letters which have addressed below in the order which were raised_ NOMS and NKS England consider the Coroner's expert's opinion On the risks associated with tobacco withdrawal; Both NOMS and NHSE agree that, while comprehensive assessments are completed when prisoner is received into prison custody in relation to their health and risk of harm to Self and others, further consideration needs to be given to the extent to which screening processes should identify tobacco dependence and potential issues associated with withdrawal Currently, prisoners undergo a number of assessments on their arrival in prison custody: Prison Service Order (PSO) 3050 "Continuity of Healthcare for Prisoners, contains mandatory requirement that requires that an initial assessment of the healthcare needs of ali newly received prisoners is undertaken within 24 hours of first reception by an appropriately trained member of the healthcare team to identify any existing probiems and to plan any subsequent care. A health screen..takes place before the prisoner's first night to primarily detect: immediate physical health problems immediate mental health problems significant drug or atcohol abuse risk of suicide andlor self-har The policy requires that if immediate health needs are detected, the prisoner is referred to the appropriate healthcare worker or specialist team: In addition; in the week following first reception, prisoner must be ofiered & general health assessment This assessment is equivalent to primary care assessment when registering with new practice the community. Such assessments are not standardised, however the general health assessment should act as an opportunity for: gathering further medical information checking how the prisoner is settling in health education they every
providing information health promotion As you will recall from evidence at the inquest, second reception review %f the Prisoner s smoking habits andehow fanyoigareteestibe sheeeriokerclaies She Prisoner is asked whether heigheanishencohGtop tsanokirgarndes beesed heiokos &daily: Smoking cessation programmes , which include the provision of to do so evcence acveraablerogevm risonec throcacoutthes Droveioimefin icofiody renacertrer evidence given explained how diazepam can be prescribed necessary to alleviate the effects of tobacco withdrawal Iiaaddition;Prison Service Instruction 74/2011 'Eariy days in custody reception in, first igetatiocusode ardinduction t0 custody : inciudes tne requiremenofor aneneiaiocreenirg in relation to the prisoner's mood; prisoner must_ be interviewed; in private if to discover &nd record any further immediate needs and risks, and possible_ about the_prisoner that may be relevant; particularly any other information Furthermore, it requires that "The PER during their first night in custody" Suicide & Self and any other available documentation including Warning Forms, ACCT documents and CSRA assessments; must Ing fxathered and the prisoner interviewed in Reception, to assess the risk of self-harm orhare to others by the prisoner, or harm from others NO1es caccepts that despite the above range of screening during the reception process, fuaheiconsideration needs to be given to identifying prisoners fornghor tObaccowvithorawai may give rise to an increase in suicidal feelings or self-harm, and to develop the" given to prisoners who do not have access to tobacco, or to the amount would support Tely or NOMS is currently working with healthcare partners to develop they normally includes an appropriate level of screening, to ensure a care pathway, that is available but in that when tobacco is not available, or it more limited supply than the level are used to (because inited riundslaccess to prison shop}: that the relevant healthcare provderuensuees' that appeopeate support including Nicotine Replacement Therapy is available VThs ierrecognised as especially important in cases of poly substance users and those with mental health issues. Ireadditionp Vou WIl be interested t2 know that the Offender Health and Tobacco Cessation Teamseat Public Health England (PHE) are currently working on guidanceOioaCrsonsintine management of people with nicotine addictions_ As this guidance is not yet completed, PHE recommends that healthcare providers responsible for the assessment and treatment of tobacco withdrawal follow the NICE Public Health Guidance (PH45) on Tobacco Harm Reduction; which recommends that When tobacco is notavailable; Or itOi avaiaabe barin more limited supply that Nicotine Replacement Therapy is made available to supplement tobacco use. Facilitating access to extra nicotine can prevent users experiencing nicotine withdrawal and the side effects that this may cause: HMP Belmarsh review the areas of concern regarding the implementation of ACCT, that were raised during the inquest ACCLcase reviews National policy contained within PSI 64/2011 Management of prisoners at risk of harm to Self; to others and from Others (Safer Custody)" reminds staff of the mandatory requirement that ACCT-case reviews "Be multi-disciplinary where possible": Colleagues at HMP Belmaesh have . confirmed that the Goveror and all managers (including custodial managers and sudervising officers) Will attend further ACCT Case Manager refresher traininageparerta underline the importance of a multidisciplinary attendance at case reviews,andgthen need to seek contributions relevant departments, including healthcare staff and mental health the the help The Harm they they have from from
professionals This refresher training will commence this month and is expected to be completed by October 2014_ Initerms of attendance at ACCT case reviews; the policy recognises that The ACCT del operate more effectively # there $ continuity in ineeafendanceaf steef Aror relecant departmentsservices For example, if education is seen as & relevant department to attend the review; then every efiort should be made to ensure the samee memberzotneat ateredd the releiews; likewise with healthcare input. The Enhanced Case RevieweTeamtaill invote tal relevant disciplines and include more specialists and higher level of operational management than typical ACCT Case Review Team. Colleagues at Belmarsh have Tfirced that the refresher training will remind al managers tnataheadofany planner tbeaticCT Case Manager will undertake 3 handover with the new Case Manager a theovew; locatiorelandihe importance Di both ACCT Case Managere aftendingethearagereviehe preor feere relocation Will be reiterated, In addition, Case Managers will aiso becremindeevoPthe reed to gather all relevant information and to allow those attending ACCT case reviews rte review ACCT and any risk related information SystmOne) which Review Team need to be may possess (for example, on aware Of_ rithinethe ACCT process; the ACCT Assessor is expected to gather and review all available risk related information including that contained within the NOMIS notes, the F2050 (prisoners core record): and any recent ACCTs etc to inform the assessment All relevant risk information should be recorded within the ACCT, and attendees at the first ACCT review and subsequent case review meetings are expected to beeamiliarewitht he contents Of the ACCT; You will be aware that the Prisons and Probation Ombudsman that a local protocol was devised to ensure that information recommended custody and healthcare staff, and as a result members ofathe was shared between safer now record interaction with prisoners mental health in-reach team within the ACCT subject to on open ACCT both o SystmOne and document Case Managers have been reminded of the need to follow up hay beentalhealth referrals and are now required to follow up any referralse ensurionat? has been received and actioned this will also be addressed in current ACCT refresher Roining7 therocal policy %n Suicide Prevention (which is auertohee crerieguec On Tofrearer
2014) and a Notice to Staff to be issued on 3 March 2014. National policy requires that staff ensure that a case manager or representative from the receiving residential unit Is invited to attend a case review ahead of a planned relocation Withincthe prison the purpose of Which [s to ensure that all relevant informatior ardociakos shared and understood_ ACCI CAREMAPS Chapter 5 of PSI 64/2011 sets out the purpose of the ACCT case review which include: Consider and record progress against the initial CAREMAP; and the prisoners general welk- being; Consider whether the prisoner exhibits any additional needs which may require the CAREMAP to be updated; Discuss with the prisoner the meaning of any act8 of self-harm and options for alternative coping strategies Celleongues at Belmarsh have confirmed that ACCT case managers Will be reminded during theiongoing ACCT refresher training and in the updated local policy of the requirementih9 review the CAREMAPS at each case review and record the manager Who is responsible for each action and who is required to feed back at tne next case review. the they the the
A review of the records on SystmOne and the CAREMAP should have highlighted the fact that Mr Johnson had been referred for a mental health assessment but this had not been completed_ Location _in the segregation unit Policy allows prisoners subject to ACCT procedures to be located in the segregation unit in exceptional circurstances: The reasons must be clearly documented in the ACCT Plan and include others options that were considered but discounted" . In Mr Johnson's case, staff in the healthcare centre were concerned that Mr Johnson had become aggressive, and was threatening to damage and "kill someone" if he remained there_ Staff were concerned that he therefore presented danger to other patients, and his perceived attempt to assault Governor led to his relocation in the segregation unit While it is apparent that the Governor who authorised the segregation was not aware 0; Mr Johnson's ACCT or the potential triggers when he was relocated from the residential unit to the segregation unit; his risk was recognised by the Nurse completing the initial segregation safety algorithm (which requires confirmation of an open ACCT, as well as signs that they are acutely unwell) and accepted by the Governor. The reasons for him relocated to the segregation unit were documented by those attending the enhanced case review team who (as the PPO reported) thought he should remain there due to the outstanding charges (concerning the damage to his cell his attempted assault on the Governor) , and aiso because he was permitted to smoke there, which case review team recognised remained an extremely important concern to him: It is acknowledged in policy and accepted by colleagues at HMP Belmarsh that prisoners who are subject to ACCT procedures should be located in segregation units only in exceptional circumstances, and that this point will be reinforced during the ongoing ACCT refresher training hope you find this letter helpful:
providing information health promotion As you will recall from evidence at the inquest, second reception review %f the Prisoner s smoking habits andehow fanyoigareteestibe sheeeriokerclaies She Prisoner is asked whether heigheanishencohGtop tsanokirgarndes beesed heiokos &daily: Smoking cessation programmes , which include the provision of to do so evcence acveraablerogevm risonec throcacoutthes Droveioimefin icofiody renacertrer evidence given explained how diazepam can be prescribed necessary to alleviate the effects of tobacco withdrawal Iiaaddition;Prison Service Instruction 74/2011 'Eariy days in custody reception in, first igetatiocusode ardinduction t0 custody : inciudes tne requiremenofor aneneiaiocreenirg in relation to the prisoner's mood; prisoner must_ be interviewed; in private if to discover &nd record any further immediate needs and risks, and possible_ about the_prisoner that may be relevant; particularly any other information Furthermore, it requires that "The PER during their first night in custody" Suicide & Self and any other available documentation including Warning Forms, ACCT documents and CSRA assessments; must Ing fxathered and the prisoner interviewed in Reception, to assess the risk of self-harm orhare to others by the prisoner, or harm from others NO1es caccepts that despite the above range of screening during the reception process, fuaheiconsideration needs to be given to identifying prisoners fornghor tObaccowvithorawai may give rise to an increase in suicidal feelings or self-harm, and to develop the" given to prisoners who do not have access to tobacco, or to the amount would support Tely or NOMS is currently working with healthcare partners to develop they normally includes an appropriate level of screening, to ensure a care pathway, that is available but in that when tobacco is not available, or it more limited supply than the level are used to (because inited riundslaccess to prison shop}: that the relevant healthcare provderuensuees' that appeopeate support including Nicotine Replacement Therapy is available VThs ierrecognised as especially important in cases of poly substance users and those with mental health issues. Ireadditionp Vou WIl be interested t2 know that the Offender Health and Tobacco Cessation Teamseat Public Health England (PHE) are currently working on guidanceOioaCrsonsintine management of people with nicotine addictions_ As this guidance is not yet completed, PHE recommends that healthcare providers responsible for the assessment and treatment of tobacco withdrawal follow the NICE Public Health Guidance (PH45) on Tobacco Harm Reduction; which recommends that When tobacco is notavailable; Or itOi avaiaabe barin more limited supply that Nicotine Replacement Therapy is made available to supplement tobacco use. Facilitating access to extra nicotine can prevent users experiencing nicotine withdrawal and the side effects that this may cause: HMP Belmarsh review the areas of concern regarding the implementation of ACCT, that were raised during the inquest ACCLcase reviews National policy contained within PSI 64/2011 Management of prisoners at risk of harm to Self; to others and from Others (Safer Custody)" reminds staff of the mandatory requirement that ACCT-case reviews "Be multi-disciplinary where possible": Colleagues at HMP Belmaesh have . confirmed that the Goveror and all managers (including custodial managers and sudervising officers) Will attend further ACCT Case Manager refresher traininageparerta underline the importance of a multidisciplinary attendance at case reviews,andgthen need to seek contributions relevant departments, including healthcare staff and mental health the the help The Harm they they have from from
professionals This refresher training will commence this month and is expected to be completed by October 2014_ Initerms of attendance at ACCT case reviews; the policy recognises that The ACCT del operate more effectively # there $ continuity in ineeafendanceaf steef Aror relecant departmentsservices For example, if education is seen as & relevant department to attend the review; then every efiort should be made to ensure the samee memberzotneat ateredd the releiews; likewise with healthcare input. The Enhanced Case RevieweTeamtaill invote tal relevant disciplines and include more specialists and higher level of operational management than typical ACCT Case Review Team. Colleagues at Belmarsh have Tfirced that the refresher training will remind al managers tnataheadofany planner tbeaticCT Case Manager will undertake 3 handover with the new Case Manager a theovew; locatiorelandihe importance Di both ACCT Case Managere aftendingethearagereviehe preor feere relocation Will be reiterated, In addition, Case Managers will aiso becremindeevoPthe reed to gather all relevant information and to allow those attending ACCT case reviews rte review ACCT and any risk related information SystmOne) which Review Team need to be may possess (for example, on aware Of_ rithinethe ACCT process; the ACCT Assessor is expected to gather and review all available risk related information including that contained within the NOMIS notes, the F2050 (prisoners core record): and any recent ACCTs etc to inform the assessment All relevant risk information should be recorded within the ACCT, and attendees at the first ACCT review and subsequent case review meetings are expected to beeamiliarewitht he contents Of the ACCT; You will be aware that the Prisons and Probation Ombudsman that a local protocol was devised to ensure that information recommended custody and healthcare staff, and as a result members ofathe was shared between safer now record interaction with prisoners mental health in-reach team within the ACCT subject to on open ACCT both o SystmOne and document Case Managers have been reminded of the need to follow up hay beentalhealth referrals and are now required to follow up any referralse ensurionat? has been received and actioned this will also be addressed in current ACCT refresher Roining7 therocal policy %n Suicide Prevention (which is auertohee crerieguec On Tofrearer
2014) and a Notice to Staff to be issued on 3 March 2014. National policy requires that staff ensure that a case manager or representative from the receiving residential unit Is invited to attend a case review ahead of a planned relocation Withincthe prison the purpose of Which [s to ensure that all relevant informatior ardociakos shared and understood_ ACCI CAREMAPS Chapter 5 of PSI 64/2011 sets out the purpose of the ACCT case review which include: Consider and record progress against the initial CAREMAP; and the prisoners general welk- being; Consider whether the prisoner exhibits any additional needs which may require the CAREMAP to be updated; Discuss with the prisoner the meaning of any act8 of self-harm and options for alternative coping strategies Celleongues at Belmarsh have confirmed that ACCT case managers Will be reminded during theiongoing ACCT refresher training and in the updated local policy of the requirementih9 review the CAREMAPS at each case review and record the manager Who is responsible for each action and who is required to feed back at tne next case review. the they the the
A review of the records on SystmOne and the CAREMAP should have highlighted the fact that Mr Johnson had been referred for a mental health assessment but this had not been completed_ Location _in the segregation unit Policy allows prisoners subject to ACCT procedures to be located in the segregation unit in exceptional circurstances: The reasons must be clearly documented in the ACCT Plan and include others options that were considered but discounted" . In Mr Johnson's case, staff in the healthcare centre were concerned that Mr Johnson had become aggressive, and was threatening to damage and "kill someone" if he remained there_ Staff were concerned that he therefore presented danger to other patients, and his perceived attempt to assault Governor led to his relocation in the segregation unit While it is apparent that the Governor who authorised the segregation was not aware 0; Mr Johnson's ACCT or the potential triggers when he was relocated from the residential unit to the segregation unit; his risk was recognised by the Nurse completing the initial segregation safety algorithm (which requires confirmation of an open ACCT, as well as signs that they are acutely unwell) and accepted by the Governor. The reasons for him relocated to the segregation unit were documented by those attending the enhanced case review team who (as the PPO reported) thought he should remain there due to the outstanding charges (concerning the damage to his cell his attempted assault on the Governor) , and aiso because he was permitted to smoke there, which case review team recognised remained an extremely important concern to him: It is acknowledged in policy and accepted by colleagues at HMP Belmarsh that prisoners who are subject to ACCT procedures should be located in segregation units only in exceptional circumstances, and that this point will be reinforced during the ongoing ACCT refresher training hope you find this letter helpful: