Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0297, written 14 Nov 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Nov 2013 |
|---|---|
| Reference | 2013-0297 |
| Deceased | Anthony Brian Flynn |
| Coroner | Jennifer Leeming |
| Coroner area | Manchester (West) |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. Mr Jeremy Hunt MP, Secretary of State for Health Director of HMP Forest Bank 1 CORONER I am M Jennifer Leeming, Senior Coroner for the Coroner Area of Manchester West 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 1st October 2012 I commenced an investigation into the death of Anthony Brian Flynn, aged 41 years. The investigation concluded at the end of the inquest on 31st October 2013. The conclusion of the inquest was that Anthony Brian Flynn had died of metastatic testicular carcinoma, and that this was a natural cause of death. 4 CIRCUMSTANCES OF THE DEATH In or about 2010 at the Royal Preston Hospital Anthony Brian Flynn was diagnosed to be suffering from testicular cancer. On the 24th July 2012 he was remanded into custody and taken to Forest Bank Prison, Salford, where he remained until his death on the 28th September 2012. 5 CORONER’S CONCERNS 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 unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) Anthony Brian Flynn was admitted to HMP Forest Bank on 24th July 2012. He was at the time of that admission suffering from diagnosed testicular cancer. (2) From time to time during Mr Flynn’s imprisonment he was escorted to clinical appointments at various hospitals. He also spent time as an in- patient. On these occasions he was accompanied by prison officers and was handcuffed and chained. 1 (3) On the 10th September 2012, a Consultant Clinical Oncologist at the Royal Preston Hospital who was treating Mr Flynn, wrote to HMP Forest Bank expressing concerns. She said “I was extremely concerned that there was an absolute lack of compassion demonstrated to what was a very sick man who was extremely distressed in the clinic. Unfortunately I felt that there was no really empathy in terms of the huge amount he had already received treatment for the significant side effects he has had and certainly conducting my examination of the abdomen and pelvis including the genitalia in a sensitive manner was extremely difficult.” Evidence given at the Inquest confirmed that Mr Flynn had been chained and handcuffed during the examination to which the Doctor refers. (4) letter was received at HMP Forest Bank, but it was never acknowledged. No reply was sent, nor were the matters of concern described in the letter, especially that the Doctor had found it ‘extremely difficult’ to conduct the examination of Mr Flynn, ever investigated. (5) Further evidence given at the Inquest revealed that: a) When a prisoner is being escorted to hospital or other appointments escorting officers can, if they consider it appropriate, telephone the prison and seek permission to remove or lengthen the prisoner’s restraints. b) Clinicians have the power to request that the action described in a) be taken, but most clinicians are unaware that they can do this. (6) The evidence concluded that there was a need to consider the following: a) The training of prison officers in relation to escorting prisoners, particularly during hospital visits. b) Procedures for making clinicians, particularly hospital clinicians, aware of their powers in relation to prisoners attending for treatment. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9th January 2014. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr Jeremy Hunt MP, Secretary of State for Health Director of HMP Forest Bank 2 Prison & Probation Ombudsman I am also under a 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 representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated Signed 14th November 2013 M Jennifer Leeming 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
*
sodexo
JUSTICE SERVICES
Our Ref: FB/DIC/A.FLYNN
HM Coroner Ms J Leeming
Bolton Coroners Court
Paderbom House
Howell Croft North
Bolton
BL1 1QY
02 January 2014
Dear Ms J Leeming
Re: Regulation 28 correspondence Mr Anthony Flynn
In response to your report dated 14 November 2013 sent under paragraph 7,
Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of
the Coroners (Investigations) Regulations 2013 and as a result of the inquest into
the death by natural causes of Mr Anthony Flynn at HMP Forest Bank; | have
reviewed the training of prison officers in relation to escorting prisoners,
particularly during hospital visits and the procedures for making clinicians,
particularly hospital clinicians, aware of their powers in relation to prisoners
attending for treatment within HMP Forest Bank.
| set out below the action which has been taken by the prison and future plans
which we are endeavouring to implement in the New Year.
A Safer Custody, Cell Sharing Risk Assessment (CSRA) and Escort & Bedwatch
awareness days have been planned to take place on 22™, 23 and 24" January
2014. Our aim is to speak to all staff (including non operational staff). Part of the
sessions will include an examination of the Escort & Bedwatch paperwork and
the conduct expected of staff. Speakers will ncuce lll Custody
Manager, a s Custody Senior Officer, Operations
Manager and Quality Assurance and Risk Co-ordinator. Following the
event, a small questionnaire will be completed by each member of staff to ensure
they have gained sufficient knowledge in each area.
In addition, a programme of training for prison officers who conduct escorts
(particularly during hospital visits) is being implemented. This will include a guide
to good practice and will reinforce the behaviour we expect of officers whilst
performing bedwatch duties. The officers will be made aware that failure to
adhere to such standards may result in disciplinary action.
STOP HUNGER
oy INVESTORS
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| enclose a copy of the escort/bedwatch booklet which has been prepared to give
to staff to remind them of their duties whilst out on escort and to ensure staff are
conversant within the arrangements for the removal of restraints where there is
an immediate risk to the health of the prisoner or to facilitate essential treatment.
The booklet is also going to be used for training purposes and staff will be asked
to sign to say that they have received the training and understand what is
expected of them.
A Prison Manager will visit the hospital at least once in each 24 hours. During the
visit, there will be an assessment of the current security arrangements to ensure
that they remain as previously assessed and where possible take into account
the views of medical staff, subject to their availability.
Finally, | was concemed to learn thai letter did not receive the
attention that it should have. Accepting entirely that the letter should have been
acknowledged and dealt with, an Operational Instruction has been re-issued to
remind and reinforce to staff that all correspondence received regarding a
prisoner should be sent to the Performance Delivery Unit which will examine,
record and liaise with the relevant department to ensure that a coordinated
response is provided within a maximum of 20 working days. | enclose a copy of
the Operational Instruction which was recently re issued.
Grateful to you for the matters you have raised and trust you find my
response to\be appropriate and helpful.
Director
STOP HUNGER
Agecroft Road - Pendlebury - Salford M27 8FB Wf 7% INVESTORS
Tel: 401619257000 Ext 2303 {yf IN PEOPLE e
Sodexo Limited - No 842846 - England - Registered Office - One Southampton Row - London - WC1B SHA
www.sodexojusticeservices.co.uk A Soden iitatee
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