Finding the time, finding the
person, finding a new way..?
Patricia Cadden, Senior Commissioner
And
Chris Hart, Independent Nurse
Consultant
What we’ll be talking about
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Introduction
Reasons for commissioning the RDIC Custody
Taking a moment
The work to date
Too busy, not enough staff, what to do?
What next?
London deaths in prison custody/ detention
2013-2016
12
10
8
2013-14
2014-15
6
2015-16
2016-17
4
2
0
Natural causes
Self-inflicted
Accidental (sus OD)
Other
Unknown at this point
2013-2016
HMP WS
HMP WW
HMP PV
HMP TS
HMP BM
HMP Isis
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Resuscitation and emergency
response/roles
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Communication between
doctors/nurses and prison staff
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Emergency response
procedures
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ACCT management- healthcare
input/recording
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Records management- meeting
professional standards
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Assessment completion
processes (clinical curiosity)
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Risk assessments- internal and
for escorts out/on release
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Protocols for observations and
escalation (recording of clinical
measurements)
Continuity of care (to and from
community/hosp/court)
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Skill mix of staff in key areas
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Management of selfharm/suicide
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DNAR protocols- re:
communicating to staff
End of life
care/pronouncement of death
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IRC HW
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Commissioning Chris
• Observation- seeing healthcare teams/units at
work
• Processes- assessment/communication
flows/staff support/ systems and governance
• Identification- what are the actual issues?
• Support- using his expertise and experience work
with management and teams to agree change
• Evaluate/sustain-what can be done to address
cultural blocks/bring about a more dynamic
workforce/new ways of working
Taking a moment
The work to date – initial phase
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3 day initial visit
Introducing the process
Talking with people
Observation of the detail of policy, practice
and systems
• To date: HMYOI Feltham, HMPs Wandsworth,
Belmarsh and Thameside
Early findings – no surprises
• Intense pressure on all staff arising from prison
population and its needs
• Difficulty balancing ‘security’ and ‘care’
• Complexity of healthcare provision
• Difficulty integrating healthcare service into life of
the prison
• Difficulty maintaining systems
• Functional, task oriented approach often misses
the person
Extremely difficult for staff to see
prisoner’s whole story and risk
How do we relate to the person?
How might ‘busyness’ affect us?
“No one cares”
“No one listens”
Yet…among the staff group
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Resilience
Perseverance
Commitment
Striving
Compassion
Phase two
• Designing bespoke developmental packages
with staff from each individual service
• Working with healthcare teams
• Working with prison staff
Phase two
• Providing resources
• Working alongside staff
• Learning and developmental forums
• Reflective practice sessions
The problem of resources
What do we mean by “short staffed”?
• A commonly used term
• What does it actually mean?
– Insufficient numbers of people to carry out
assigned tasks?
– More work than we’ve previously had without an
expansion in staff?
– Fewer staff than previously available for the same
amount of work?
– A combination of the above?
What do we mean by “short staffed”?
• A question of staffing levels but also the ratio of
staff to the amount of work to be undertaken
• Situation changes i.e. fewer staff but do we
adapt?
• Some temporary measures but not moving into
new mode of operation
• Trench warfare rather than guerrilla warfare or
trying to run a country estate on the budget for a
semi detached semi.
“It’s all about management!”
• Emotionally intelligent management
• Inclusive
• Incorporating methodology of shared
governance
• Focused on risk management and effective
performance
Prioritising
• What are the key problems we’re trying to
solve/issues we’re trying to address?
• What are the must dos?
• How was this decided? Does everyone know?
Do they agree?
What cannot be done?
• What does this mean we can’t do?
• Do the right people know we can’t do things?
• Do they understand, acknowledge and
support this?
Team working
• Who is in my team? Do they know they’re in
my team?
• What is the team’s focus?
• What is their role? Is this clear?
• How collaborative is everyone?
• What are my carrots?
Delegation
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If someone has a task, are they ready for it?
How do I/they know?
What has been done to prepare them for it?
Are we utilising people’s skills to the full?
Have we got skills based training in place?
Communication
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What needs to be communicated?
Who should do this?
What systems are in place?
How do people know what has happened on
the previous shift, today’s priorities, who will
be doing what and when?
Organisation
• Do we work in a totally reactive environment?
• How can we plan ahead and try and stick to
those plans [bearing in mind the best plans
are those that never have to encounter
‘reality’]?
Not just what can we do differently
but how?
Hope
• Importance of Hope
• Limited ambition – sticking to achievable aims
rather than leaving people feeling perpetually
defeated e.g. “what have we achieved today
and what can we achieve tomorrow?”
Clinical risk indicators for suicide
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Previous self-harm
Family history of suicide
Previous use of violent
methods
Unemployed/retired
Suicide plan/expressed intent
Male gender
Current suicidal
thoughts/ideation
Separated/widowed/divorce
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Hopelessness/helplessness
Post natal depression
Peurperal psychosis
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Lack of social support
Depression
Family concerned about risk
Evidence of psychosis
Disengaged from services
Alcohol and/or drug misuse
Poor adherence to
psychiatric treatment
Chronic physical illness/pain
Access to lethal means of
harm
Discharged from hospital
within last 7 days
Other, specific, clinical factors in
prisons
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Previous trauma
Lack of coping strategies
Anxiety
Poor physical health
Recent stressors
The prisoner might trivialise/conceal their risk
indicators/vulnerability
Contextual risk factors
• Predisposing factors e.g.
– Previously in institutional ‘systems’ e.g. care as a
child etc
– The nature of the offence
– Loss of support networks e.g. family relationships
– Prisoners are isolated
– Lack of contact with others
• Bullying
Working a little differently…
What can come from an extra few
minutes
What might we look for?
• How robust is the Reception interview?
• Does everyone get seen for 2nd day
assessment and other appointments?
• What systems do we have in place –
– For minimising DNAs
– For medicines administration
– For risk assessment
– To promote multi professional working
– For effective communications
Beyond the systems
• Are we agreed on the core task?
• How well do we work together?
• What are the relationships –
– Within teams
– Between teams
• Are our skills and competencies at the right
level?
Scope for small changes
• How involved are staff in making changes?
• How receptive are we to ideas?
• What kind of support is available to all?