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Coroner orders closer working between five trusts after prisoner’s death

PUBLISHED

Five NHS trusts in the South West have been ordered to make immediate improvements after the death of a 20-year-old prisoner who needed healthcare.

Lewis Francis was arrested in Wells, Somerset, in 2017 after stabbing his mother while “acutely psychotic” and taken into custody. Although his condition mandated a transfer to a medium secure mental health hospital, there was “no mechanism” in place to move Mr Francis and he was taken to prison, where he died by suicide two days later, according to a coroner.

Contributory factors to his death included “insufficient collaboration, communication and ownership between and within organisations… together with insufficient knowledge of… the Mental Health Act,” according to Nicholas Rheinberg, the assistant coroner for Exeter and Greater Devon.

In a Prevention of Future Deaths report, Mr Rheinberg said a memorandum of understanding was in place for the transfer of “mentally ill prisoners direct from police custody” in the West Midlands, and he called on the South West Provider Collaborative to agree a similar deal with “relevant organisations and agencies”.

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Source: HSJ, 14 July 2020

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