Reggie Johns
16 Sept 2013 · Coroner G U Williams · Worcestershire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of written record of discussions between governors
“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”
2. inadequate reasons for not holding multidisciplinary meeting
“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”
3. officer left review prematurely without speaking to healthcare staff
“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”
4. nurse not given ACCT document and failed to document professional view
“failure of the nurse to be provided with the ACCT document when Mr [name redacted] was interviewed by her and her further failure to make any entry within that document detailing her professional view”
5. insufficiently robust and detailed review of high-risk prisoner
“lack of communication and a lack of sufficiently robust and detailed review of Mr [name redacted] involving all appropriate personnel”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr [name redacted] was interviewed by her and her further failure to make any entry within that document detailing her professional view.”
Later report
“that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
Responses
2013-0202-Response-by-NOMS.pdf ↗· HMP Hewell
Stated action
“Since Mr [name redacted]' death, HMP Bristol has introduced a 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”
2013-0202-Response-by-Worcestershire-Health-Care-NHS.pdf ↗· Worcestershire Health and Care NHS Trust
Stated action
“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”