Peter Stanley
2 Sept 2014 · Coroner Peter Dorries · South Yorkshire ( West)
The coroner's concerns
1. use of legal high
“[the deceased]'s mental health problems may have stemmed from the use of a so called 'legal high'”
2. lack of step-down policy for discharged young people
“When young people are discharged from, or have failed to engage with, Adult Mental Health Services there is no formal 'step-down' policy”
3. lack of awareness of out-of-hours access to records
“On the basis of evidence given by Assistant Director of Fieldwork Services, Sheffield City Council, it is clear that the custody nurse could have accessed the Children's Services records for [the deceased] on 14 July, even during the night, by calling the Social Services 'out of hours' team”
4. absence of mandatory mental health assessment in custody
“There is no specific requirement that health professionals completing assessments of young persons in custody suites include a thorough assessment of mental health”
5. missing PER handover to Youth Offending Service
“A prisoner escort record (known commonly as a PER) would have been handed over from the police to the privatised court detention officers when [the deceased] was produced before the magistrates”
6. misclassification of homelessness status
“[the deceased] was classed as 'intentionally homeless' after his release from court on 15 July”
Responses
2014-0390-Response-by-NOMS.pdf ↗· Department for Education
Stated action
“PECS has agreed with the police via ACPO that information on risk relating to detainees (including risk of self-harm and suicidal intent) is communicated via the Prisoner Escort Record (PER) form. It is this information supported by the receiving staffs own dynamic assessment of risk that informs the form of care the individual will receive.. This may in exceptional circumstances include the removal of clothing, continuous observation by staff etc but this is not the normal default position. Our”