Andrew Shirley: Prevention of future deaths report

Mental Health related deathsState Custody related deaths

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Date of report: 27/01/2023

Ref: 2023-0063

Deceased name: Andrew Shirley

Coroner name: David Reid

Coroner Area: Worcestershire

Category: State Custody related deaths | Mental Health related deaths

This report is being sent to: Various

1        CORONER
I am David Donald William Reid, HM Senior Coroner for the coroner area of Worcestershire
I make this report under paragraph 7, Schedule 5, of the Coroners end Justice Ad 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
On 31.3.21 an investigation was commenced Into the death of Andrew Paul SHIRLEY, a prisoner at HMP Hewell who died in his cell at the prison on 23.3.21 having deliberately suspended himself by a ligature. He was 25 years of age at the time of his death.

This investigation concluded at the end of the inquest on 20.1.23.

The medical cause of death was: 1a external neck compression (hanging).

The conclusion of the inquest was as follows:
“Andrew Shirley died as the result of deliberately suspending himself by a ligature. It Is not possible to determine what his intention was et the time he did this.

See questionnaire.
1. Did healthcare and mental healthcare staff at HMP Hewell:
(a)take sufficient steps to Identify and record Andrew’s risk of suicide and/or self-harm? NO
(b)put In place sufficient measures to try to reduce the risk of suicide and/or self-harm, whether ( for example ) by locating Andrew on the Targeted Care Pathway, opening an ACCT document, recording concerns on the Initial Segregation Health Screen document, formulating· e mental health care plan, or otherwise ? NO
(c)share sufficient information about Andrew’s risk of suicide and/or self harm with prison staff, so as to.enable prison staff to make appropriate decisions themselves about reducing the risk? NO

2. If any of your answers to Questions 1(aHc) above Is NO
(a) did that failure/those failures probably cause or contribute to Andrew’s death on 23 March2021? YES

(a) on 20.3.21 should the Duty Governor, after reading the Initial Segregation Health Screen document before making the decision that Andrew should remain on the Segregation Unit, have made any more enquiries about the answers given on that document? YES

If YES to Question 3(a):
(b) would those enquiries probably have had to further information being provided about an increased risk of Andrew committing an act of suicide or self-harm? YES

If YES to Question 3(b):
(c) should the Duty Governor have taken any action to try to reduce that risk ( e.g. by opening an ACCT document)? YES

4. If YES to Question 3(c):
(a) Old the failure to take such action probably cause or contribute to Andrew’s death? CANNOT SAY
(b) If NO or CANNOT SAY to Question 4(&), did that failure possibly cause or contribute to Andrew’s death on 23 March 2021? YES

Neglect 5. Was Andrew’s death contributed to by neglect? YES
In answering the questions “when, where, how and in what circumstances did Andrew come by his death, the jury found as follows:

“On 23.3.21 Mr. Andrew Shirley was found unresponsive in cell 14 of the Segregation Unit at HMP Hewall suspended by a ligature. Advanced life saving measures were undertaken but he was pronounced dead at the scene st 1944hrs.”

To clarify, at the time of these events Andrew was a diagnosed paranoid schizophrenic who had been receiving a monthly depot injection of anti-psychotic medication. He also had a documented history of self-harm end suicide attempts. Andrew had been in police custody from 25.2.21 until 1.3.21, during which time he had undergone a formal Mental Health Assessment at the Cauldon Centre, Coventry because of concerns about his mental health. Those conducting that assessment concluded that he did not require treatment in a psychiatric hospital, whether as e detained or voluntary inpatient.

Following a court hearing on 1.3.21, Andrew was remanded Into custody to await trial, end was taken to HMP Hewell.

At the prison, Andrew’s mental health history was noted and he was allocated a mental health care coordinator. During the three weeks that Andrew was at the prison, his care-coordinator failed to carry out any in-depth mental health assessment of him, failed even to begin to formulate a mental health care plan for him, and failed properly to assess and manage his risk of suicide and/or self-harm. The overall failings of the healthcare and mental healthcare teams sit the prison are reflected in the answers of the Jury to Questions 1, 2 and 5 In the Jury Questionnaire (above).

Throughout his time at the prison, Andrew said on several occasions that he felt that his medication was not working.

On 20.3.21 Andrew was placed In the Segregation Unit at the prison, following in incident in which he spat at two prison officers.

In order to assist the Duty Governor In deciding whether Andrew could be held safely on the Segregation Unit, a nurse completed an initial Segregation Health Screen document, in which she recorded that Andrew was currently on anti-psychotic medication. In addition, during the course of her assessment of Andrew, he told her that he was hearing voices which were telling him to kill himself, and that he wanted a radio so that he could drown those voices out. That information was not relayed to the Duty Governor, but the Duty Governor accepted in his evidence that, in light of the information that Andrew was on antipsychotic medication, he should have spoken to, end sought further Information from the nurse.

In their answers to Questions 3 end 4 In the Jury Questionnaire, the July found that, had the Duty Governor sought this further information, he would probably have taken action to reduce Andrew’s risk of suicide and/or self-harm ( e.g. by opening an ACCT document ), and his failure to do so possibly caused or contributed to Andrew’s death on 23.3.21.

Two further Initial Segregation Health Screen documents were completed on 22.3.21, by a paramedic end mental health nurse respectively.

In the first of those the paramedical concerned concluded that there were no “healthcare reasons” not to segregate Andrew at that time. That conclusion was based on two wrong answers in the algorithm contained within that document. The paramedic conceded that she had neither seen Andrew, nor looked at his medical records before completing this document.

The mental health nurse who completed the second Initial Segregation Health Screen document also conceded that he had not seen Andrew beforehand, and accepted in evidence that he might have reached a different conclusion if he had read entries contained within Andrew’s medical notes.

Andrew was found collapsed and unresponsive in his cell on the following evening of 23.3.21, suspended by & ligature. He was confirmed deceased at the scene later that day.
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur until action is taken. In the circumstances It is my statutory duty to report to you.

The MATTERS Of CONCERN are as follows

(1) I heard evidence that v.8 of the ACCT document had been in place at prisons throughout England and Wales since June 2021, and that training relevant thereto consists of:
(I) ACCT v.6 training; and
(II) SASH ( suicide end self-harm) modal 3 training.

However, I also heard that, as at 20.1.23 (over 18 months after the introduction of the latest ACCT document ), 280 out of 400·members of staff at the prison ( 70% ) were yet to have completed that training. It is of considerable concern that such a high percentage of staff at the prison may not be in a position recognise the risk which a prisoner presents of suicide and/or self-harm, and therefore, to take appropriate steps to reduce that risk;

(2) I also heard evidence that, despite the introduction of a new initial. Segregation Health screen algorithm document for prisoners In the Segregation Unit, Duty Governors at the prison had not yet received any training about the steps they should take In order to complete that document appropriately.
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action by conducting an Investigation Into the deficiencies and failures outlined above, and ensuring that appropriate training Is provided to all relevant staff.
You are under a duty to respond to this report within 56 days of the date of this report. namely by 24.3.23. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action Is proposed.
I have sent a copy of my report to the Chief Coroner end to the following:
Bimberg Peirce solicitors, who represent Andrew’s family;
[REDACTED] Chief Executive of HM Prison end Probation Service;
[REDACTED], HM Chief Inspector of Prisons; chair of the Independent Advisory Panel on Deaths In Custody;
[REDACTED] Practice Plus Group;
[REDACTED] Midlands Partnership NHS Foundation Trust;
The Prison end Probation Ombudsman.

I am also under e duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both In a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find It useful or of interest. You may make representation to me, the coroner, at the time of your response, about the release or the publication of your respond by the Chief Coroner.
9D.D.W. Reid H.M.Senior Coroner for Worcestershire 27th January 2023