Source · Prevention of Future Deaths

Reggie John

Ref: 2013-0202 Date: 16 Sep 2013 Coroner: G U Williams Area: Worcestershire 2 responses identified · 3 indexed addressees View PDF

AI-generated concerns summaryConcerns included insufficient communication between prisons regarding the prisoner's constant watch status, a lack of robust multi-disciplinary ACCT review processes, and instances where the Prison Service Order 2700 policy was not followed, impacting healthcare documentation.

Date 16 Sep 2013

56-day deadline 11 Nov 2013 est. estimated from the report date

Responses identified 2 of 3

State Custody related deaths

Coroner's concerns

AI summary

Concerns included insufficient communication between prisons regarding the prisoner's constant watch status, a lack of robust multi-disciplinary ACCT review processes, and instances where the Prison Service Order 2700 policy was not followed, impacting healthcare documentation.

View full coroner's concerns

(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell where aware that Mr Johns was on an open ACCT were not made aware of his constant watch status (2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate. It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare_ This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol causes significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review: Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.

(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any within that document detailing her professional view: Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel: Whilst the Safer Custody process has_ am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.

Responses

2 respondents

Worcestershire Health Care NHS

NHS Trust

Indexed date: 15 Oct 2013 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Trust stated it would ensure appropriate information is communicated to receiving prisons upon prisoner transfer. • The Trust confirmed that expectations for nurses reviewing and documenting Assessment, Care in Custody and Teamwork (ACCT) documents for prisoners in reception were set out and reiterated to all staff. • The Trust indicated that Prison Service Instruction 64/2011 was reviewed to identify and address areas of non-compliance.

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Dear Mr Williams Re: Reggie Johns (deceased) Regulation 28 Coroners and Justice Act 2009 Thank you for your letter dated 16 September 2013 and the enclosed Regulation 28 report have read your report with great care and in particular the concerns you have raised as a result of your investigation into Mr Johns' death_ have also discussed this report with the lead for Offender Health and the Head of Healthcare, HMP Hewell do not intend to comment on your report in terms of the circumstances of Mr Johns' death. have read this section of your report and have discussed it with who confirms that it is an entirely fair reflection of the evidence given during the course of the inquest With regard to your Matters of Concern propose to consider each of these in turn: Communication Whilst this concern largely focuses on the issue of communication between HMP Bristol and HMP Hewell think it is appropriate to seek to reassure you about communication between the healthcare team at HMP Hewell and other HM Prisons There is continuous dialogue within HMP Hewell between the healthcare and the discipline teams: Some of this is formalised through various meetings and forums and some is informal and reflects a relatively constant ebb and flow of communication on patient specific issues, task related discussion, operational issues and joint working: If prisoners are transferring to other prisons the prisoner's healthcare record is transferred to the receiving prison. In some cases the Nurse in Reception at HMP Hewell will contact the receiving prison to raise specific issues or concerns Messrs and Iwill ensure that appropriate information is communicated to receiving prisons Chairman: Chris Burdon Chief Executive: Sarah Dugan RECEIVED HM: CORONER

when prisoners are transferred from the prisons in which the Trust provides healthcare services, namely HMPs Hewell, Long Lartin and Oakwood_ 2 Prison Service Order 2700 Healthcare provides representation into Assessment; Care in Custody and Teamwork (ACCT) reviews as follows: prisoners in the Inpatient Unit (Lower Medical) prisoners in the segregation unit prisoners actively managed by the mental health team part of Multi-Disciplinary Team discussion any other prisoner if requested by the prison (this may be telephone advice or attendance at the review).
3. ACCT Document At the time of Mr Johns' inquest when this issue was discussed wrote to all staff within the healthcare team at HMP Hewell to set out his expectations in respect of prisoners arriving in Reception at HMP Hewell on an ACCT. These are as follows: The ACCT document is made available to the Nurse in Reception_ This has been discussed with the Reception Governor to ensure that Prison Officers undertake to do this The ACCT document must be reviewed while the prisoner is in Reception A note must be entered into the ACCT document regardless of the level of risk presented by the prisoner A note must be made in the reception screen or subsequent healthcare record that the ACCT has been seen and reviewed and any actionslplans are recorded. Subsequently these requirements have been re-iterated to all staff_ can also confirm that following the inquest into Mr Johns' death and Prison Governor, HMP Hewell have reviewed Prison Service Instruction 64/2011 (updated) in order to identify any areas of non-compliance and to address these_ trust that the foregoing has adequately addressed the Regulation 28 report issued subsequent to the inquest into Mr Johns' death_

HM Prison and Probation Service

Central Government

Letter dated 7 Nov 2013 PDF

AI-classified response stance Action Taken

AI-generated response summary

• HMP Bristol implemented a system for its safer custody team to contact receiving establishments and escort contractors regarding prisoners on open ACCTs, with these communications recorded on Prison-NOMIS. • HMP Hewell issued staff guidance and notices on making quality records on C-NOMIS and ensuring multi-disciplinary ACCT reviews. • HMP Hewell and Worcestershire Primary Care Trust produced a joint document on information sharing, and ACCT documents are now available to nursing staff in reception.

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Dear Mr Williams Death of Mr Reggie Johns on 20 October 2010 Thank you for your Regulation 28 Report of 16 September addressed to the Governors of HMP Hewell and HMP Bristol: NOMS Equality; Rights and Decency Group (ERD) is responding to this report as we have ownership of suicide prevention and self-harm management policy in prisons. This letter is also being sent on behalf of the Governors of HMP Hewell and HMP Bristol: You identified a number of concerns in your report These have been taken very seriously and have provided details below about the action that has been taken to address these issues since Mr Johns death Recording Infgrmation You were concerned about the sharing and recording of information by staff at the two prisons when Mr Johns transferred from HMP Bristol to HMP Hewell via Redditch Magistrates Court Since Mr Johns' death HMP Bristol has introduced system whereby their safer custody team contacts the receiving establishment via email and telephone whenever a prisoner on an open ACCT transfers out of the prison to make the receiving establishment aware of the prisoner's perceived risk of harm: In addition, the escort contractors are also now informed of those prisoners on open ACCTs prior to being transferred out to court or other establishments_ These conversations are recorded on Prison-NOMIS and the enclosed Governor's Order has been issued to remind staff of their responsibilities in this area.

At HMP Hewell the enclosed Staff Information Notice entitled 'C-NOMIS Case Notes' has been issued since Mr Johns' death to remind staff of the need to make quality records on C-NOMIS of all conversations with prisoners andlor their families which are relevant to ensuring the safe management of that prisoner_ A new local safer custody guidance document has been also issued at HMP Hewell since Mr Johns' death to accompany PSI 64/2011. Within this guidance there is a section about information recording which states: AIl staff at HMP Hewell have a responsibility to inform the relevant people if they have received information from any source that indicates a change in potential for a prisoner to harm themselves If you have received such information, you must immediately pass this on to the Residential, Daily or Night Operational Manager: You can also open an ACCT Plan and make a recording in an appropriate source, e.g- observation book, NOMIS or an SIR Always report this information could save someone's life. Multi-disciplinary ACCT Reviews You highlighted that the ACCT review at HMP Hewell upon Mr Johns' arrival was not multi-disciplinary and no member of the healthcare team was in attendance or spoken to to the meeting taking place_ Since Mr Johns' death; the enclosed Operational Orders have been issued entitled 'Chairing ACCT Reviews' and 'ACCT Reviews' which provide guidance for selecting appropriate ACCT case managers, and confirm that it is the case manager's responsibility to ensure that each review is multi-disciplinary with views from all appropriate departments being taken into consideration Access to ACCTDocuments You identified that when Mr Johns arrived at HMP Hewell the nurse who carried out a medical assessment did not have access t0 his ACCT document: am aware that you are now in receipt of Worcestershire Health and Care NHS Trust's response to your report; which confirms that ACCT documents are now made available to nursing staff in reception in all cases when a prisoner arrives at HMP Hewell on an open ACCT. In addition to that response have enclosed a copy of a joint document which has been produced by HMP Hewell and Worcestershire Primary Care Trust which provides guidance to discipline and healthcare staff about the importance of working together and sharing information appropriately about the prisoners in their care_ hope that you find this response helpful and reassuring:

Report sections

Investigation and inquest

On 27th October 2010 commenced an investigation into the death of Reggie Johns then aged 58_ The investigation concluded at the end of the inquest in the presence of a jury on September 2013. The returned a narrative verdict in the following terms: "Mr Johns committed suicide, contributing factors that provided Mr Johns the opportunity to commit suicide were the lack of communication between departments when reviewing Mr Johns ACCT document and deciding to remove him from constant watch without the appropriate input from the relevant qualified persons involved"_

Circumstances of the death

Mr Johns had been a former life sentence prisoner who was recalled to prison in March 2010 after 18 years in the community: He spent time at HMP Hewell_ HMP Long Lartin and HMP Bristol having been moved between establishments because of his behaviour in the prisons concerned. On the 17th October 2010 whilst at HMP Bristol Mr Johns was placed on an ACCT form and was the subject of constant watch because of two separate attempts to hang himself: Previously during his time at Hewell he had been placed on protective measures on not less than 3 occasions and similarly at Bristol on two occasions_ Mr Johns was due to appear at Redditch Magistrates Court on 19"h October and, because of operational problems, HMP Bristol refused t0 agree that he should be returned there_ 11" Jury The

There was limited communication between HMP Bristol and HMP Hewell but ultimately HMP Hewell agreed to accept Mr Johns from Redditch Magistrates court Mr Johns appeared at Redditch Magistrates Court and was remanded to HMP Hewell where he arrived in the mid afternoon on the 19"h October 2010. At that stage his constant watch status became apparent to the staff at Hewell: At Hewell his ACCT status was reviewed by prison officers who decided not to continue his constant watch status. He was placed in a cell, where some 6 hours later he was found hanging from a ligature fashioned from a bed sheet: He was taken to hospital where he died the next day Upon arrival at Hewell he underwent a health screen from a female nurse from the Healthcare Department: That nurse gave evidence saying that she was told that Mr Johns was to be placed in the segregation unit on constant watch. This lead her to conclude that there were no matters which were of concern to her because, as she said plainly in evidence, everything that could be done for Mr Johns was (insofar as she had been told) going to be done. That nurse that although she was aware that an ACCT review was to take place she was not consulted about it, took no part in it and made no contribution towards it She said in terms that the two individual prison officers who in fact conducted the review did not atany time speak to her or seek t0 elicit her view on the matter. Her view on the matter was that Mr Johns should remain on constant watch to enable him to settle into the prison_ Two prison officers conducted the review_ One of those officers left half way through the review leaving Mr Johns in the company of his colleague_ No member of the Healthcare Department or any other member of staff was present at the review One of the officers gave evidence to the effect that when he was notified of Mr Johns arrival at the prison he spoke to a member of Healthcare staff who confirmed that there were "no issues" with Mr Johns_ He was however unable to identify even the gender of the person to whom he said he had spoken. The other prison officer (the one who left the review early) gave evidence to the effect that; having left the review; he spoke to a male member of Healthcare who confirmed that there were issues The evidence reasonably clearly demonstrated that there was no male member of Healthcare involved with Mr Johns at any stage: The officer who remained with Mr Johns in the review gave evidence that he knew Mr Johns from his previous time in Hewell; that he believed that they had a good relationship and that he could, therefore; be satisfied that when Mr Johns said he had no intend to harm himself that he could be believed. two very said "no

Mr Johns was therefore (with the concurrence of both of the prison fficers) placed on normal location rather than in segregation or the Healthcare Department; removed from constant observation because in the opinion of the prison officers there were no issues" and that the issues which precipitated HMP Bristol placing Mr Johns on constant watch had been dealt with: It appeared from the evidence and was clearly the basis of the jury's conclusion that there was an inadequate review conducted in this case.

Action should be taken

In my opinion action should be_taken to prevent future deaths and believe YOU have_the_power they Policy entry to take such action

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Report details

Reference: 2013-0202
Date of report: 16 September 2013
Coroner: G U Williams
Coroner area: Worcestershire

Responses identified

Responses identified 2 of 3

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Nov 2013 (estimated from the report date).

Sent to

HMP Bristol

HMP Hewell

Worcestershire Health and Care NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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