Jai Singh

1. 1. failure to use interpreters poor communication and record keeping insufficient engagement with family insufficient use A

   “A multitude of factors contributed to Mr. [name redacted] death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. [name redacted] safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. [name redacted] family, insufficient”

2. 2. absence of psychiatrist in mental health MDT and lack of ongoing risk assessment documentation

   “the mental health team multi-disciplinary team (MDT) does not include a psychiatrist; and ii. the absence of any ongoing risk assessment documentation for patients with mental illness within the SystemOne records at HMP Birmingham”

3. 3. lack of rolling risk assessment documentation in SystemOne

   “Other electronic health care records systems used in mental health settings have a rolling risk assessment document that clinicians are required to review and update at certain points in a patient's management. The risk assessment document provides a prompt to clinicians to formally consider risk and come to a reasoned, documented conclusion that then feeds into decision making. The record also provides a reliable, easily accessible source of risk history. No such facility is in use on SystemOne”

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