Mr Everest — HMP Altcourse

In 2017/18 as a result of NICE guidance for the physical health of people in prison (NICE guidance [NG57] and the publication of new standards on optimising medicines for people in secure environments (Royal Pharmaceutical Society 2017)), NHS England introduced a formal medicines reconciliation process so that information about prescribed medicines is verified via community sources. This reconciliation should be completed within 72 hours of admission.

In 2018 a national template was introduced for medicines reconciliation to ensure a consistent approach that meets national standards for this activity. Performance against this expectation is measured via national Health & Justice (H&J) indicators of performance (HJIPs).

Whilst awaiting verification, critical medicines (as defined by the national patient safety alert and NICE guidance) should be continued unless clinically justified on safety grounds not to be. Non-critical medicines can be safely omitted until verification is received with patients being given reassurance that the omission is safe and a decision to prescribe the medicine will be made within 3-4 days. The Royal Pharmaceutical Society standards include this expectation as part of the standards relating to continuity of medicines on admission to an H&J setting.

The decision to continue or stop a prescribed medication that was initiated in the community rests with the prison clinician This will be based on their individual clinical assessment of the patient and safety of the medicine based on the outcomes of that assessment and co-morbidities/medicine interactions. This is line with GMC guidance on Good practice in prescribing and managing medicines and devices.

At HMP Altcourse, the GP summary is requested the day after reception by the healthcare administration team and will be chased up if not received from the GP surgery.

HMPPS recognises that families can provide vital insights into a prisoner’s behaviour and motivations and that, depending on the circumstances, involving family members in the ACCT process may prove beneficial. A safer custody learning bulletin that was produced in December 2017 explains the benefits of involving families in the ACCT case management process for those at risk.

We know that access to family and loved ones can act as a protective factor for many people. A person’s family or significant other may well also be in a good position to know when something is wrong, and to spot signs of improvement. They can also offer insight into past behaviour, what is ‘normal’ for that individual and what support has helped in the past. We have therefore emphasised the importance of family support as part of ACCT v6, encouraging family members and loved ones to be seen as valuable partners within the ACCT process who can help to inform the support put in place for residents. In order to achieve this, we have clearly set out expectations for when family engagement would be appropriate (noting that this will not be the case for all residents in our care) and offering practical guidance on how this can be achieved. This is reflected in policy, staff guidance and staff training. We have also improve the ACCT documentation itself so that this information can be easily and consistently recorded, alongside consent for family involvement, for use throughout the ACCT process.

ACCT version 6 has been rolled out across the prison estate and was introduced at HMP Altcourse in July 2021 .
In instances where individuals have given consent for family involvement and it is felt that family input would be beneficial, Case Managers or the Safer Custody team at HMP Altcourse will contact family members and encourage their participation in the ACCT process.

Suicide and self-harm trained Peer Supporters (Carers) are utilised throughout the ACCT process at HMP Altcourse where a roster is in place to show which Carers are on duty each day/evening. Both staff and prisoners can request a Carer to support individuals, which may include staying with them overnight in various care suites throughout the prison. Any Carer support offered and accepted is logged within the ACCT book.

The HMPPS policy Prison Service Instruction 15/2017 ‘Prisoners Assisting Other Prisoners’ describes the principles that apply to all formal arrangements for prisoners to provide assistance to other prisoners and sets out the contribution that prisoners may appropriately make to meeting the care and support needs of other prisoners, and what is not appropriate for them to do. Peer support does not replace any of the responsibilities of staff to manage and support prisoners, but seeks to enhance this.

At HMP Altcourse all observation levels are decided upon on an individualised basis taking into account all aspects of risk, history, protective factors and presentation rather than directed by policy, in accordance with national guidelines. Decisions are then documented in the ACCT.

Within ACCT v6 there is an improved focus on recording risks, triggers, and protective factors. The document contains a dedicated form which is updated throughout the process, allowing any member of staff to quickly identify someone’s risks, triggers, and protective factors, to ensure that tailored support that is responsive to risk can be established for the individual. All appropriate and meaningful actions are now recorded on the Immediate Action Plan and on the Support Actions Form in ACCT v6.

In July 2017, HMPPS produced a safer custody learning bulletin ‘ACCT – Case Reviews, CAREMAPs and Levels of Conversations and Observations’. It states that the frequency of ACCT conversation and observations should be set at a level that reflects the assessed risk, and that people with a raised or high risk of suicide are likely to require a higher frequency of observations. The bulletin provides additional information on setting the frequency of observations in an annex.

Guidance on constant supervision can be found in Chapter 6 of Prison Service Instruction 64/2011 ‘Management of Prisoners At Risk of Harm to Self, to Others and From Others (Safer Custody)’. Constant supervision is a response to an immediate suicidal crisis and therefore is intended to be in place for the shortest time possible.

Safer cells are designed to assist staff in the task of managing those at risk from suicide by ligaturing as they are designed to minimise ligature points. Safer cells can only complement (i.e. not replace) a regime providing individualised and multi-disciplinary care for at-risk prisoners.

Criteria for placement in safer cells or for constant supervision is clearly laid out within the local policy at HMP Altcourse, which is compliant with national guidelines.

All prisons must have systems in place to receive and act promptly on information received in an emergency, in line with the policy framework on Strengthening Prisoners’ Family Ties, which came into effect on 31 January 2019.

HMPPS recognises that the intervention of a third party may be crucial in alerting staff that a prisoner is at risk, so it is important that families and friends know that prisons value their input, that any concerns raised about a loved one will be acted on appropriately and that where possible they receive feedback when they do get in touch.

In March 2019, HMPPS issued two Prison Safety Learning Bulletins entitled ‘How to respond to contact from family members and friends of prisoners who are concerned about their wellbeing’ and ‘Sharing information with a prisoner’s family and/or friends: when can it be done and what can be disclosed?’ These bulletins reminded prisons that families and visitors of prisoners should be encouraged to share risk information with prisons and be provided with contact details that can be used in emergencies, and provided guidance about the importance of having consent, what information it is appropriate to share, and when it is legal and appropriate to disclose that information without consent.

Additionally, HMPPS issued a Safety Briefing on emergency contact from family and friends in November 2019. In summary, every prison must have:
1. A contact process that is advertised to family members and stakeholders by a variety of means, including online and via the family services provider;
2. A means of speaking to a member of staff (duty governor /orderly officer/person in charge of residential unit) immediately about situations involving imminent risk, as well as an answering machine for less urgent matters on which calls are monitored regularly and followed up;
3. Instructions for staff receiving such calls about how to respond sensitively and what actions to take, including prompt feedback to the person who raised the concern.
4. A system for logging calls that provides assurance that action has been taken, and ensures that the information received informs the ongoing care of the individual prisoner.

HMP Altcourse has a Safer Custody Helpline that is available for anyone outside the prison to ring and be directed to Safer Custody staff during core hours. This number is displayed in the visits centre, visits hall and is given out to anyone ringing the prison.

Outside of core business hours an answerphone is in operation for messages to be left or for more urgent calls the caller is directed to the prison control room who would contact the relevant on site manager for immediate action. This call and subsequent action would be logged within both the control room log and Duty Director log.

HMPPS recognises that families can provide vital information about a prisoner’s history.

In December 2017, HMPPS issued a safer custody learning bulletin entitled ‘Engaging Families or Significant Others with ACCT Case Management’. The bulletin explains the benefits of involving families or in the ACCT case management process for those at risk and encourages prisons to consider inviting families to attend case review meetings, in person or via teleconference, or to contribute in advance by phone or email. Prisons are asked to keep the family member informed of all developments.

ACCT v 6 places greater emphasis on the involvement of families in the ACCT process, where consent has been given, and it recognises that a person’s family can offer insight into past behaviour, what is ‘normal’ for that person and what support has helped in the past. In this way, they can be a valuable addition to the multi-disciplinary team supporting the individual.

In line with local, regional and national guidelines, family involvement is a consideration for all staff that support prisoners within the ACCT process at HMP Altcourse.

Where individuals have given consent for family involvement, and it is felt that family input would be beneficial, Case Managers or Safer Custody staff at HMP Altcourse will contact family members and encourage their participation in the ACCT process.

HMP Altcourse remains compliant with PSI 64/2011 Management of prisoners at risk of harm to self, to others and from others (Safer Custody) and all regional and national guidelines.

As part of the HMPPS 10 Prison Project family engagement programme, Clinks1 worked with a group of prisons to produce a series of ‘Think Family’ resources explaining how prisons can develop a ‘Think Family’ approach. The resources are accompanied by four briefings, including one on effective communication with families, which sets out the benefits and encourages two-way communication channels between prisons and families.

HMPPS recognises the importance of information sharing and how this can play an important role in the care of prisoners.

Information sharing is key to delivering safer custody that is coordinated around the needs of the individual. It is essential to enable early intervention and preventative work, to promote the wellbeing and for wider public protection.

Prison staff may receive information about a prisoner from a variety of sources. All staff who receive information, including from concerned family members, or observe changes in a prisoner’s behaviour which indicates a change in the risk they pose to themselves, to others and/or from others must communicate their concerns immediately to the Residential, Daily or Night Operational Manager, and/or consider opening an ACCT Plan and make a record in an appropriate source e.g. observation book, NOMIS, Security Information Report, ACCT Plan.

At HMP Altcourse, contact with prisoners is recorded in either SystmOne (healthcare and counsellors) or NOMIS (prison staff, including chaplains).

Complex cases are managed in conjunction with the Safer Custody team who will attend reviews to offer further support and expertise. All ACCT information is now held on the Custodial Management System (CMS) which includes details of ACCT reviews. All staff have access to CMS.

Current practice at HMP Altcourse is for any incident of serious self-harm or serious assault to be reported via a serious incident questionnaire and reported to the national & regional Safer Custody teams. The Director at HMP Altcourse will decide on the level of investigation, taking into account any feedback received from the national Safer Custody team. Any other issues arising would be investigated locally using appropriate methodology.

The results of investigations are reviewed by the Head of Safer Custody and any learning is fed back to the staff involved and prison as a whole via staff written notices, management meetings, staff training and awareness sessions.

Family Liaison Officer positions are advertised for those staff who have an interest in carrying out this sensitive and challenging role at HMP Altcourse. Interviews are undertaken to ensure that those selected have the appropriate skills and experience to undertake this role sensitively and compassionately. Selected officers then attend the Family Liaison Officer Training run by the national HMPPS training team. The Safer Custody team regularly reviews the suitability of the staff assigned to this role.

A Safer Custody Manager and/or Duty Director carries out a formal debrief with staff involved for all serious incidents. Counselling is on offer for any member of staff that feels they have been affected by an incident.

Additionally, Care Teams in prison can provide post-incident peer support, information and signposting to their colleagues.

As a result of the NICE guidance [NG57] Physical health of people in prison, a first-stage health assessment should be carried out that should include referring the person for mental health assessment where appropriate, but also questioning the person about their prescribed medications, documenting any being taken and referring to the prescriber for appropriate medicines to be prescribed to ensure continuity of medicines.

The guidance also advises that if medicines are being taken, the healthcare professional should ensure the next dose has been provided and let the person know that medicines reconciliation will take place before the second-stage health assessment.

Clinicians are expected to follow national guidance on the reduction or cessation of medicines and initiation of new medicines. This was highlighted in a 2017 NHS England publication “Health and Justice mental health services: Safer use of mental health medicines”.

The formulation of mirtazapine used is based on local risks and local mental health formularies based on the local primary care CCG formulary or secondary care Mental Health Trust formulary (for specialist mental health indications). The timing of mirtazapine administration (where this is provided under supervision/not in-possession) is based on local arrangements that depend on the regime of the prison.

At HMP Altcourse, all new admissions into the prison who are identified as having a medical need or request to see a GP will be seen within their first 24 hours, including at weekends. Confirmation of their medication will be gained from community services.

GPs ensure that any changes to prescribed medication are managed in accordance with relevant guidelines. Due to the sedative effect of this type of medication, it is good practice to issue it in the evening as is done at HMP Altcourse. However, the GP can consider issuing the medication in the morning period and would highlight their decision on the prescription. This type of medication is not allowed to be held in the possession of the prisoner.

The Head of Security or Security Manager at HMP Altcourse carries out a full risk assessment when a prisoner is admitted to hospital. This risk assessment, along with follow up assessments, always takes into account the cuffing and escort strength for each individual person. This will also set out whether staff should be present during visits and medical examinations.

HMP Altcourse staff will engage with the family both sympathetically and with respect when carrying out bedwatch duties. The feelings of the family will always be considered.

The NHS England national service specification for prison based Mental Health Services in England, published in March 2018, provides standards for the mental health pathway from reception to transfer or release. The service specification informs the contract for the secondary mental health services commissioned by NHS England.

At HMP Altcourse, mental health assessments are conducted as soon as possible upon admission and/or receipt of the referral. New admissions are often seen within a 24-48-hour period and any offender placed on an ACCT will be seen within 24 hours of the referral being received with mental health nurses attending all ACCT reviews.

The introduction of the mental health pathway in April 2019 introduced the TAG scoring assessment tool, which allows for the better allocation of offenders as it assesses the severity of an individual’s mental health problems. The RMNs now all have their own caseloads to ensure continuity of care and consistency.

The healthcare administration team requests the GP summary the day after reception. For prisoners identified with mental health needs or who have been referred to the Mental Health Pathway, Mental Health Admin will request additional information from external secondary care mental health. The relevant healthcare practitioner will review the information received and the information will be available to all SystmOne users.

Please see the response to recommendation 3 above; the expectation is that in urgent cases a mental health assessment is carried out within 48 hours.

In respect of the carrying out of a mental health assessment, the national service specification requires that the role of the team in the assessment and onward referral to psychiatrist is clearly defined and in agreement with the prison establishment, and that “the mental health assessment uses a standardised format, which includes a relevant previous history, an assessment of mental health, intellectual and developmental disabilities, substance misuse, psychosocial factors, risk to self and others.”
Guidance: Standard mental health assessment tools are used and they are compliant with NICE guidelines.

At HMP Altcourse, the Mental Health Team will attend and asses offenders within 48 hours when an urgent referral is received. A referral to the secondary Mental Health Team, including referral to a psychiatrist, will also be considered where appropriate.

The NHS England service specification for Prison Mental Health Services in England contains an appendix regarding ‘Standards for 24 Hour Mental Health Care in Prisons.’ Establishments that have a 24 hour mental health facility should also work to the standards embedded within this Appendix. One of the standards is that :

“Patients have a comprehensive assessment which is started within 4 hours and completed within 48 working hours. This involves the multi-disciplinary team and includes the patient. An immediate care plan is completed which includes:
• mental health and medication;
• physical health needs;
• risk assessment, including risk of suicide.
• Where appropriate, the Mental Health Team will participate in the ACCT process as part of a multi-disciplinary team”

At HMP Altcourse, someone admitted as an inpatient to healthcare will have a full assessment, including a mental health assessment if necessary, and care plans are developed accordingly. If the inpatient is on an ACCT, relevant information will be shared with the ACCT Case Manager to inform the next case review.

A joint briefing is held every morning to discuss the medical and operational needs for the running of the Inpatient Unit (IPU). Risk and ACCT information is shared at the briefing, which is attended by nurses and prison officers. At the end of each shift a handover of the unit takes places and staff coming on duty will be briefed by the outgoing staff about risks, ACCT information and any incidents that have occurred.

The Mental Health Team visits the IPU on a daily basis and is available for additional visits should they be required in times of crisis. The regime and activities schedule has been reviewed by the mental health team and it now allows for patients within the unit to take on purposeful activity.

The Mental Health Team will also attend ACCT case reviews as part of the multi-disciplinary team.

The NHS England service specification provides a responsibility for the proportionate sharing of information between both healthcare and non-healthcare staff to ensure the safety of prisoners and staff and the management of risk.

The standards that are essential to a safe mental health service are described as below in the specification:
• The team receives training consistent with their roles on risk assessment and risk management. This is refreshed in accordance with local guidelines. This training includes, but is not limited to training on:
1. Safeguarding vulnerable adults and children;
2. Assessing and managing suicide risk and self-harm;
3. Prevention and management of aggression and violence.
• The team actively participates with the Assessment, Care in Custody and Teamwork (ACCT) process in managing the risk of self-harm and suicide.
Guidance: The mental health team attends or contributes to all ACCT reviews for prisoners under their care. They are involved in decisions about location, observations and risk.

On the Inpatient Unit (IPU) at HMP Altcourse, healthcare staff attend all ACCT reviews in order to share relevant information. Additionally, handovers occur where required between both healthcare and operational staff, particularly when prisoners are on open ACCTs and there is a heightened risk of harm to self. In many cases, the prisoner is present at their ACCT review and shares their own information. However, if there is a particular need to share extensive medical information in order to provide the best care to the prisoner then the healthcare team will obtain the prisoner’s consent to share the relevant information. The healthcare team always considers the risk to the prisoner, and others, if information is not shared.

Prisoners being managed on ACCT are highlighted on the roll board within the IPU office. Both operational and healthcare staff handover ongoing ACCT records during shift changes. IPU healthcare managers regularly contact Safer Custody for information when ACCT reviews are due.

As noted in the response to recommendation 6, the national mental health service specification provides a number of outcomes and standards of care for assessment both at the reception and post reception stage. An expected outcome to help achieve Objective 2 is “Where appropriate, the Mental Health Team will participate in the ACCT process as part of a multi-disciplinary team.”

The mental health assessment uses a standardised format, which includes relevant previous history, an assessment of mental health, intellectual and developmental disabilities, substance misuse, psychosocial factors, risk to self and others. Guidance: Standard mental health assessment tools are used and they are compliant with NICE guidelines.”

At HMP Altcourse, a risk assessment is completed on all new arrivals into the prison. This risk assessment is part of the Initial Health Screen and covers concerns regarding vulnerability and risk to self and others. A Cell Sharing Risk Assessment is also completed for all new arrivals at the prison. Both operational and healthcare staff complete this assessment, which allows for a joint approach to be taken when assessing a prisoner’s risk of harm to self and others, and whether they are able to share a cell.

A new version of ACCT (ACCT v6) was rolled out nationally in July 2021 and updated Suicide and Self-harm training providing guidance on the effective management of the ACCT process has been delivered to all ACCT Assessors and Case Managers.

ACCT Assessors will attend first case reviews, wherever possible. If they cannot attend, the ACCT Assessor must meet with the Residential Case Manager prior to the first case review and give a detailed summary of the assessment discussions and key issues.

PSI 64/2011 recognises that the ACCT process will operate more effectively if there is continuity in the attendance of staff from relevant departments/services. For example, if education is seen as a relevant department to attend the review, then every effort should be made to ensure the same member of staff attends the reviews.

HMP Altcourse has adopted a Single Case Manager Model which ensures consistency of the Case Manager regardless of the prisoner’s location. Case Managers will ensure the consistency of attendance of other staff at ACCT reviews , wherever possible.

Additionally, ACCT v6 promotes the involvement of key workers with ACCT if possible, as they will be individuals that have an ongoing, positive and trusted relationship with the prisoner, which will help with the consistency of the process. This may put them in a better position to monitor progress or notice changes to behaviour or presentation (especially where ACCTs are open for prolonged periods of time) and will be able to contribute to supporting them in a coordinated and meaningful way.