Liam Smith
18 Sept 2015 · Coroner Geraint Williams · Worcestershire
The coroner's concerns
1. inadvertant self harm
“Evidence suggested that Mr [name redacted] was at risk of inadvertant self harm and that therefore in accordance with PSI64/2011 ACCT procedures should have been opened in respect of him”
2. medical information not disseminated
“medical information which arrived at the prison with Mr [name redacted] was not disemminated to those in reception or those who had later dealings with him”
3. relevant information not accessed
“Healthcare Staff indicated that they do not always read relevant sections of the System 1 notes and that the "summary page" of System 1 does not always "pull through" relevant important information”
4. limited interaction with high risk drug users
“Evidence suggested only limited interaction between members of Healthcare Staff and prisoners who were deemed as "high risk drug users" with a concern that warning signs are missed”
Responses
2015-0382-Response-by-NOMS.pdf ↗· Governor HMP Hewell
Stated action · within the first quarter of 2016
“The Trust has confirmed that they have now changed their practices relating to high risk drug users. The initial contact for those undergoing any type of detoxification is from the caseworker who has contact the day after the person is received into the prison. Additionally, a follow up ledger to SystmOne has been introduced within three working days of the detoxification programme ending. An audit will be undertaken within the first quarter of 2016 to check that the processes are working effectively”