PFD report

JACK OLIVER PORTLAND · Prevention of Future Deaths report

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Issued 21 Feb 2017•Buckinghamshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
16

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
31

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised16

  1. Failure of communication between healthcare staff and prison staff about healthcare records
  2. Failure to complete timely and accurate Root Cause Analysis reports
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable root cause analysis processes
  3. Failure to establish and communicate a clear AWOL and leave authorisation procedure
    Part of recurring concern: Unreliable AWOL response processesPart of recurring concern: Unreliable mental-health patient leave arrangementsPart of recurring concern: Unsafe management of inpatient leave and absence
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.23

  1. Action

    Test the new leave-management SOP on Sapphire ward, review it, and expand implementation across all adult wards.

    Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2017.
  2. Action

    Review RCA investigator training and develop an additional module on involving and working with families.

    Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
  3. Action

    Introduce a standard requiring all investigators to complete refresher RCA training at least every three years.

    Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Providing patients or families copies of leave forms is not mandatory under the Mental Health Act Code of Practice or Trust policy.

    Stated by Oxford Health NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of communication between healthcare staff and prison staff about healthcare records

Wider context from the report

“(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete timely and accurate Root Cause Analysis reports

Wider context from the report

“(5) The actions taken in relation to the preparation of two Root Cause Analysis reports were of concern in that the first RCA was founded on inaccurate information and the second RCA still contained inaccuracies and was not completed until some 11 months after the fatal event. The ability to react quickly to issues raised and to implement new policies and working practices may have been compromised by the delays and lack of robustness of the reports. The recommendations of the second RCA indicate reviews to be conducted by February/March 2017 but do not appear to address more urgent practical action or possible staff training needs. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable root cause analysis processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to establish and communicate a clear AWOL and leave authorisation procedure

Wider context from the report

“(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave. There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL. ”

Is this part of a recurring concern?

Yes — Unreliable AWOL response processes; Unreliable mental-health patient leave arrangements; Unsafe management of inpatient leave and absence.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to disclose contemporaneous RCA information

Wider context from the report

“(6) Disclosure, initially to the Coroner, of contemporaneous interviews and information gathered during the early stages of the first RCA may have assisted in preventing subsequent delays and progressing the inquest process, enabling learning from any identified concerns to have been addressed at an earlier stage. In any event such notes and related documents did not form part of the disclosure. ”

Is this part of a recurring concern?

Yes — Unreliable disclosure of relevant evidence in formal proceedings.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate communication with families during the ACCT process

Wider context from the report

“(2) The standard letter notifying a family of the opening of an ACCT was non-specific and dependent upon prisoner consent, yet it was identified that the engagement of families in the ACCT process was important, particularly in the context of risk assessment. It appeared that the same letter is still in use, directing families to telephone extensions for prison staff and healthcare or a 24-hour help line. The family evidence was that communication with the prison in response to a letter received during the first ACCT was of significant concern and that they were not notified of the second ACCT. There was evidence suggesting that the helpline is now attended regularly and messages dealt with but the overall communication paths appear to remain the same. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families; Unreliable ACCT suicide and self-harm prevention processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to obtain and update patients’ risk history and assessment

Wider context from the report

“(4) Whilst evidence from Whiteleaf indicated they were very used to receiving patients with little or no history and assessing them, the evidence in this case indicated that they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr Portland’s time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history in relation to Mr Portland’s time at HMP Woodhill. It was acknowledged in evidence that knowledge of risk of self-harm recorded in the HMP Woodhill ACCT documents would have been helpful. ”

Is this part of a recurring concern?

Yes — Failure to incorporate relevant clinical history and diagnoses into care decisions; Inadequate mental health risk assessment; Incomplete clinical history-taking.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient detail in ACCT caremaps and post-closure reviews

Wider context from the report

“(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce. ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete leave observation charts contemporaneously and consistently

Wider context from the report

“(3) The manually-completed observation charts, forming the third element of an effective leave management process, were acknowledged to be filled out sometimes retrospectively, sometimes prospectively, sometimes by reference to the whiteboard (and evidence suggested amended later) rather than always being completed in the ward round. There was scope for human error and discrepancies between the various records of leave. ”

Is this part of a recurring concern?

Yes — Unreliable recording of required observations in care and custody; Unsafe management of inpatient leave and absence.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain an accurate and reliable leave tracking system

Wider context from the report

“(2) A specific request for leave from the patient would be actioned by a nursing-level assessment, authorisation of the specific leave by the nurse in charge and implementation of the leave by a staff member. A Record of Leave of Absence would be completed and signed by the patient and the staff member and that staff member would usually then write up that patient’s name and the times out and due back on a whiteboard in the office. Evidence from witnesses confirmed that there was no particular order to the whiteboard. In the case of Mr Portland, his final leave had not been written on the whiteboard correctly and his absence was not identified until well over an hour after he was due back. The evidence indicated that the whiteboard is still used in the same way, notwithstanding that it was acknowledged that there was scope for human error and that addressing the issue was a matter of urgency. ”

Is this part of a recurring concern?

Yes — Unsafe management of inpatient leave and absence.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to implement changes with clear timescales and adequate coverage of identified concerns

Wider context from the report

“(7) Whilst there were indications that there were changes being implemented, there was no clear indication of timescales nor did they address the particular concerns identified during this investigation. ”

Is this part of a recurring concern?

Yes — Failure to implement identified safety actions.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in identifying relevant witnesses and providing witness statements for coronial investigations

Wider context from the report

“(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department. Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure. Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest. ”

Is this part of a recurring concern?

Yes — Unreliable gathering of witness evidence for formal investigations; Unreliable preservation and disclosure of material for death investigations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to coordinate complete and appropriately recorded disclosure for coronial investigations

Wider context from the report

“(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department. Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure. Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest. ”

Is this part of a recurring concern?

Yes — Unreliable disclosure of relevant evidence in formal proceedings; Unreliable preservation and disclosure of material for death investigations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain contemporaneous records of AWOL actions

Wider context from the report

“(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave. There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in completing ACCT post-closure reviews

Wider context from the report

“(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce. ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide S17 leave records to required recipients

Wider context from the report

“(1) The practical implementation of S17 leave involved, firstly, the grant of leave by the consultant psychiatrist and it was mandatory to provide copies of those Records of Grant not only to the patient, but also to the family of a patient along with the Inpatient clinical team and the MHA administrator. The Care Co-ordinator and GP were also optional recipients. No copies of any of Mr Portland’s S17 Records of Grant of Leave appeared to have been provided to anyone other than the patient. The family were unaware of changes to leave and were unable to participate in the leave process or assist Whiteleaf with regard to any heightened risks. ”

Is this part of a recurring concern?

Yes — Unreliable mental-health patient leave arrangements; Unsafe management of inpatient leave and absence.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to adequately assess and manage discharge needs of vulnerable prisoners

Wider context from the report

“(3) There were concerns about the assessment and management of Mr Portland’s discharge needs from admission, particularly with regard to post-release accommodation and positive identification of registration with a GP, given that Mr Portland was homeless and that aftercare ultimately would be dependent upon GP engagement. It was accepted that it is mandatory for prisoner discharges to be undertaken in accordance with the relevant Prison Service Instruction and Early Days and Discharge Specification with all that those encompass. There remains a concern regarding the discharge of prisoners presenting with issues such as those of Mr Portland – a risk of self-harm, substance addiction, homelessness, resolving substance-induced psychosis, vulnerability. ”

Is this part of a recurring concern?

Yes — Unsafe discharge planning for vulnerable prisoners.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Test the new leave-management SOP on Sapphire ward, review it, and expand implementation across all adult wards.

Verbatim wording from the response

“In addition, a new standard operating procedure (SOP) for managing leave (appendix 1) includes the need for staff to have a discussion with the family, where appropriate consent is given by the patient, regarding the patient’s leave from the ward and to do this every time there is a change to the leave agreed.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 1 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review RCA investigator training and develop an additional module on involving and working with families.

Verbatim wording from the response

“- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: ████████. Timescale: new training to be delivered from 30th June 2017). - The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: ████████. Timescale: from 1st Nov 2017). - New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: ████████. Timescale: introduced from 1st July 2017). - The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: ████████. Timescale: 30th April 2017).”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 5 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce a standard requiring all investigators to complete refresher RCA training at least every three years.

Verbatim wording from the response

“- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: ████████. Timescale: new training to be delivered from 30th June 2017). - The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: ████████. Timescale: from 1st Nov 2017). - New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: ████████. Timescale: introduced from 1st July 2017). - The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: ████████. Timescale: 30th April 2017).”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 5 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Survey RCA investigators to assess whether training changes meet their needs.

Verbatim wording from the response

“- A survey commenced of RCA investigators in August 2016 to ensure changes in training meets their needs. - The Trust commissioned an external review of the quality of SI investigations completed in November 2016 to help the Trust to identify where and how to improve.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 5 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require hourly physical handover of observation charts, with both allocated staff checking that records are complete and accurate.

Verbatim wording from the response

“The new SOP referred to above is being tested on Sapphire ward. It clarifies and simplifies the management of leave on the ward. It gives clear instruction as to how leave is granted, the nursing level assessment, and simplifies the recording of leave on one collective ward document (appendix 2).”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require shift coordinators to sign off relevant observation and leave-record sheets before handover.

Verbatim wording from the response

“An existing SOP which covers shift co-ordination has had a new action added, which is that the shift co-ordinator signs off all relevant sheets, including observation charts, to ensure that all staff have fully completed the required paperwork, including the leave record form, and it is in order before handing over to the next shift.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 3 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Monitor RCA investigation allocation, progress and timeliness weekly, with quarterly reporting to the Board of Directors.

Verbatim wording from the response

“- A series of training sessions were held on promoting the status of families in investigations, ensuring they are central to the process (“Making Families Count”), which were co-delivered with the charity Hundred Families in May and June 2016. - The Trust has improved its capacity for completing comprehensive and timely investigations, including appointment of a dedicated, full time post of RCA investigator/author in the adult mental health directorate. This person was appointed in February 2016. - Weekly monitoring processes were introduced from July 2016 to better identify the right investigators, timely allocation of investigators and review of the progress of investigations. We now report on the timeliness of RCA investigations on a weekly basis to the Executive Team and quarterly to the Board of Directors.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 5 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Replace multiple leave-recording locations and the whiteboard with one central ward document.

Verbatim wording from the response

“The new SOP referred to above is being tested on Sapphire ward. It clarifies and simplifies the management of leave on the ward. It gives clear instruction as to how leave is granted, the nursing level assessment, and simplifies the recording of leave on one collective ward document (appendix 2).”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Commission an external review of the quality of serious-incident investigations to identify improvements.

Verbatim wording from the response

“- A survey commenced of RCA investigators in August 2016 to ensure changes in training meets their needs. - The Trust commissioned an external review of the quality of SI investigations completed in November 2016 to help the Trust to identify where and how to improve.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 5 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver the revised RCA training, including the additional family-involvement module.

Verbatim wording from the response

“- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: ████████. Timescale: new training to be delivered from 30th June 2017). - The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: ████████. Timescale: from 1st Nov 2017). - New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: ████████. Timescale: introduced from 1st July 2017). - The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: ████████. Timescale: 30th April 2017).”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 5 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Communicate AWOL procedures to staff and provide guidance and Missing Patient Action Checklists on all acute inpatient wards.

Verbatim wording from the response

“The responsibility for ensuring that patients are back from leave now clearly rests with the person allocated to carry out general observations. That staff member is also responsible for informing the shift co-ordinator, who will co-ordinate the implementation of the AWOL policy, if a patient does not return on time (appendix 3). The shift co-ordinator is always a qualified nurse.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Monitor observation-recording practice through the Matron and make the prohibition on prospective or retrospective entries explicit in the revised Observation Policy.

Verbatim wording from the response

“Staff have been strongly reminded that it is not appropriate to fill in observations paperwork prospectively or retrospectively. This is now monitored by the Matron. We are in the process of reviewing the Trust’s Observation Policy, and will ensure that this is also made very explicit within the new version. This policy review will be complete by the end of April 2017.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide dedicated full-time RCA investigator capacity in the adult mental health directorate.

Verbatim wording from the response

“- A series of training sessions were held on promoting the status of families in investigations, ensuring they are central to the process (“Making Families Count”), which were co-delivered with the charity Hundred Families in May and June 2016. - The Trust has improved its capacity for completing comprehensive and timely investigations, including appointment of a dedicated, full time post of RCA investigator/author in the adult mental health directorate. This person was appointed in February 2016. - Weekly monitoring processes were introduced from July 2016 to better identify the right investigators, timely allocation of investigators and review of the progress of investigations. We now report on the timeliness of RCA investigations on a weekly basis to the Executive Team and quarterly to the Board of Directors.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 5 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete governance approval and implement the amended section 17 leave form, including recording whether copies should be provided and to whom.

Verbatim wording from the response

“The provision of copies of leave forms is not in fact mandatory under either the Mental Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which suggests that this is the case, is misleading). Nevertheless, it is acknowledged that in many cases patients and their families find it useful to have a copy of the form in addition to being involved in discussions around the granting of any leave and conditions. The section 17 leave form has been amended and is currently going through the Trust’s governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017. The newly designed form allows the consultant to indicate, following discussions with patients and families, if copies should be provided and, if so, to whom.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 1 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete Safer Prisons post-closure checks using a quality-assurance template to verify timescales, caremap actions and closure-questionnaire invitations.

Verbatim wording from the response

“After closure of an ACCT a post closure check will be completed by the Safer Prisons team. A quality assurance template is used to check that the post closure process has been completed within timescales, that caremap actions were considered and completed prior to closure and that the prisoner has been invited to complete the closure questionnaire. As with all quality assurance checks any feedback required will be provided to the Case Manager involved.”

Source location

2017-0049-Response-by-NOMS
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement weekly wing-manager and monthly Duty Governor quality checks of ACCT and post-closure reviews, including caremap assessment and corrective feedback.

Verbatim wording from the response

“In order to provide assurance that new procedures are fully embedded and effective, a review of the establishment’s ACCT quality assurance processes took place in 2016. This led to the introduction of two new quality checks, one undertaken weekly by the wing manager and the other on a monthly basis by the Duty Governor, which assess the quality and completeness of ACCT reviews and post-closure reviews. Both checks include a section which requires managers to assess and comment specifically on the quality of caremaps, and where deficiencies are found, feedback is given to the case manager and/or wing manager who are required to take the appropriate action to rectify this.”

Source location

2017-0049-Response-by-NOMS
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop the family pathway during the May/June 2017 policy review to support active family involvement wherever possible.

Verbatim wording from the response

“During 2016 the prison has sought to further raise awareness of the value and importance of family contact and has seen significant improvement. Family members have been invited to and attended ACCT reviews, made telephone contributions and been involved in release planning for those prisoners on open ACCTs. The Safer Prisons team is planning further work with Case Managers using some of the local examples with contributions from family members and prisoners. During the review of the local Safer Prisons Policy in May/June 2017 the ‘family pathway’ will be developed to ensure active involvement of families wherever possible.”

Source location

2017-0049-Response-by-NOMS
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share immediate complex-case resettlement concerns with relevant departments by telephone and record them in prisoner case notes to address safeguarding issues.

Verbatim wording from the response

“It has also been agreed at the multi-agency meetings that any immediate concerns regarding resettlement issues in complex cases will be shared with relevant departments by an immediate phone call, and recorded on the prisoner case notes. This is to identify and address safeguarding issues, such as prisoners with accommodation issues and those suffering with mental health concerns.”

Source location

2017-0049-Response-by-NOMS
Page 3 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Undertake further Case Manager work using local examples and contributions from families and prisoners to promote family involvement.

Verbatim wording from the response

“During 2016 the prison has sought to further raise awareness of the value and importance of family contact and has seen significant improvement. Family members have been invited to and attended ACCT reviews, made telephone contributions and been involved in release planning for those prisoners on open ACCTs. The Safer Prisons team is planning further work with Case Managers using some of the local examples with contributions from family members and prisoners. During the review of the local Safer Prisons Policy in May/June 2017 the ‘family pathway’ will be developed to ensure active involvement of families wherever possible.”

Source location

2017-0049-Response-by-NOMS
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Route all future disclosure to the Coroner’s Court through Government Legal Department to avoid confusion.

Verbatim wording from the response

“Disclosure We regret that the provision of documents to this inquest was not achieved in the way that we would wish, and would like to apologise to you for the impact that this had on the inquest process. Much of this difficulty arose from the fact that, as Mr Portland died some months after his release from HMP Woodhill and when he was not in prison custody, the usual process by which prisons ensure that the paperwork required for disclosure to assist the Prison and Probation Ombudsman’s investigation and the Coroner’s Inquest is collated was not initiated. In consultation with GLD, we have agreed that in future all disclosure to the Coroner’s Court will be done through GLD to avoid confusion.”

Source location

2017-0049-Response-by-NOMS
Page 3 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the complex-case database in July 2017 for fitness for purpose and assess how information sharing supports vulnerable prisoners approaching release.

Verbatim wording from the response

“release, for example with GPs, drug services and housing. This ensures that no referrals are being repeated and that everyone involved in the resettlement plan is fully aware of ongoing and required actions. The use of the database will be reviewed in July 2017 to ensure that it is fit for purpose and to consider how this information sharing is used to provide multi-disciplinary support to the most vulnerable and at risk individuals approaching release.”

Source location

2017-0049-Response-by-NOMS
Page 3 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Enable prisoners to register with a GP before release, including timely transfer of clinical information and active registration support.

Verbatim wording from the response

“From July 2017, prisoners will be able to register with a GP practice before they leave prison. The agreement includes the timely transfer of clinical information from the prison to the GP practice, with an emphasis on medication history and substance misuse management plans, to enable better care when a new patient first presents at the practice. Prisoners will be actively supported to register with a GP.”

Source location

2017-0049-Response-by-NOMS
Page 3 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use a shared complex-case database to coordinate resettlement planning and live information sharing among the establishment and relevant support providers.

Verbatim wording from the response

“Since Mr Portland’s release from HMP Woodhill, the prison has introduced a new database system for the management of complex cases, which allows for the live sharing of information between the establishment, the CRC, Westminster Drug Project (the providers of substance misuse support) and CNWL. The database allows a coordinated approach to resettlement planning, providing information relating to any concerns or issues and appointments upon”

Source location

2017-0049-Response-by-NOMS
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Providing patients or families copies of leave forms is not mandatory under the Mental Health Act Code of Practice or Trust policy.

Verbatim wording from the response

“The provision of copies of leave forms is not in fact mandatory under either the Mental Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which suggests that this is the case, is misleading). Nevertheless, it is acknowledged that in many cases patients and their families find it useful to have a copy of the form in addition to being involved in discussions around the granting of any leave and conditions. The section 17 leave form has been amended and is currently going through the Trust’s governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017. The newly designed form allows the consultant to indicate, following discussions with patients and families, if copies should be provided and, if so, to whom.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 1 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The second RCA did not need to revisit immediate actions because the initial review had already identified them and the actions required.

Verbatim wording from the response

“An initial review is completed for every serious incident, as was the case following Mr Portland’s death. Each initial review report should be completed within 5 days of the incident/death, reviewed by the senior clinical team and also by a weekly Trust wide executive meeting. The purpose of the initial review report is to set out the initial facts known, to identify any immediate action or learning required and to help develop the scope for the RCA investigation. The initial review report into Mr Portland’s death identified three immediate actions all around the timeliness of initiating the AWOL procedure. The initial review report was shared with the CQC.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 3 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Community Rehabilitation Companies are responsible for resettlement services for prisoners serving 12 months or less.

Verbatim wording from the response

“Discharge Since 1 June 2014 the provision of resettlement services for prisoners serving 12 months and under has been the responsibility of Community Rehabilitation Companies (CRCs). The prison works closely with the provider of resettlement services at HMP Woodhill, MTC Novo CRC, which is required to provide support services relating to housing and accommodation, employment training and education, finance benefit and debt.”

Source location

2017-0049-Response-by-NOMS
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The prison can only prompt family contact, and effective involvement depends on the prisoner’s consent.

Verbatim wording from the response

“Family contact The value of family involvement for prisoners, and the significant resettlement opportunities that contact with family members presents, are recognised. However, the prison can only prompt this contact (and it could only be effective) with the consent of the prisoner.”

Source location

2017-0049-Response-by-NOMS
Page 2 · response
Published 5 March 2017

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. 1

    Ensure the Senior Matron obtains historic risk information for patients previously receiving care and treatment in prison settings.

    Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2017.
  2. 2

    Develop and introduce staff and family leaflets explaining the RCA process, standards, expectations and senior support contacts.

    Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
  3. 3

    Use quality-improvement work and weekly ward data reviews to increase timely returns from leave and address compliance or training issues.

    Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2017.
  4. 4

    Make the patient safety manager the family’s single point of contact during investigations.

    Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 March 2017.
  5. 5

    Deliver training on placing families at the centre of investigations, co-delivered with Hundred Families.

    Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 March 2017.
  6. 6

    Implement Case Manager allocation and ACCT review booking systems to manage caseloads and secure multidisciplinary attendance.

    Stated by Woodhill PrisonStated completedThe respondent said that this action was complete when they made their response on 5 March 2017.
  7. 7

    Increase resources available to facilitate Coroner’s inquests.

    Stated by Woodhill PrisonStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
  8. 8

    Deliver suicide and self-harm prevention and ACCT Case Manager training to prison staff.

    Stated by Woodhill PrisonStated completedThe respondent said that this action was complete when they made their response on 5 March 2017.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Ensure the Senior Matron obtains historic risk information for patients previously receiving care and treatment in prison settings.

Verbatim wording from the response

“In Mr Portland’s case, there was evidence of a handover from the Dene, however it is acknowledged that more effort should have been made in obtaining historic information from HMP Woodhill. This has been discussed with staff in the ward’s business meeting, and the Matron will continue to work with the team to ensure they meet the required standards of the Trust Clinical Risk Policy. This will be the responsibility of the Senior Matron who will ensure that historic risk information is obtained for those patients who have received care and treatment in a prison setting.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 3 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and introduce staff and family leaflets explaining the RCA process, standards, expectations and senior support contacts.

Verbatim wording from the response

“- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: ████████. Timescale: new training to be delivered from 30th June 2017). - The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: ████████. Timescale: from 1st Nov 2017). - New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: ████████. Timescale: introduced from 1st July 2017). - The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: ████████. Timescale: 30th April 2017).”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 5 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use quality-improvement work and weekly ward data reviews to increase timely returns from leave and address compliance or training issues.

Verbatim wording from the response

“For all acute wards there is ongoing work using quality improvement methodology aimed at increasing the number of patients who return from leave on time. This work includes weekly”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 2 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Make the patient safety manager the family’s single point of contact during investigations.

Verbatim wording from the response

“- Communication and involvement of the family in the investigations did not meet the standard the Trust expects of staff. Therefore from March 2016 the patient safety manager became the family’s single point of contact to improve communication.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 4 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver training on placing families at the centre of investigations, co-delivered with Hundred Families.

Verbatim wording from the response

“- A series of training sessions were held on promoting the status of families in investigations, ensuring they are central to the process (“Making Families Count”), which were co-delivered with the charity Hundred Families in May and June 2016. - The Trust has improved its capacity for completing comprehensive and timely investigations, including appointment of a dedicated, full time post of RCA investigator/author in the adult mental health directorate. This person was appointed in February 2016. - Weekly monitoring processes were introduced from July 2016 to better identify the right investigators, timely allocation of investigators and review of the progress of investigations. We now report on the timeliness of RCA investigations on a weekly basis to the Executive Team and quarterly to the Board of Directors.”

Source location

2017-0049-Response-by-Oxford-Health-NHS-Trust
Page 5 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement Case Manager allocation and ACCT review booking systems to manage caseloads and secure multidisciplinary attendance.

Verbatim wording from the response

“In addition to the prioritisation of training delivery, new procedures have been introduced to ensure more robust management of the process. During 2016 the Safer Prisons team introduced Case Manager Allocation and ACCT review booking systems, the aim of which is to ensure a manageable caseload for Case Managers and to ensure consistent multi-disciplinary”

Source location

2017-0049-Response-by-NOMS
Page 1 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Increase resources available to facilitate Coroner’s inquests.

Verbatim wording from the response

“We have noted your concerns and will be addressing these in the longer term by increasing the resource in place to facilitate Coroner’s inquests.”

Source location

2017-0049-Response-by-NOMS
Page 3 · response
Published 5 March 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver suicide and self-harm prevention and ACCT Case Manager training to prison staff.

Verbatim wording from the response

“ACCT Management You will be aware from the evidence given at the inquest of the significant amount of activity that has taken place at HMP Woodhill to ensure that ACCT procedures are managed robustly and in line with Prison Service policy. Extensive training in suicide and self-harm prevention has been delivered to staff since Mr Portland’s release from HMP Woodhill in 2015. During 2016 HMP Woodhill prioritised such training, and as a result over 93 per cent of managers at the prison have received Case Manager training, a significant improvement on previous years.”

Source location

2017-0049-Response-by-NOMS
Page 1 · response
Published 5 March 2017

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026