Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0270, written 16 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jun 2014 |
|---|---|
| Reference | 2014-0270 |
| Deceased | David O’Garro |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
David Andrew Llewellyn O’GARRO (died 02.06.14)
THIS REPORT IS BEING SENT TO:
1.
Governor
HMP Pentonville
Caledonian Road
London N7 8TT
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 6 June 2012, my predecessor, Shirley Anne Radcliffe, commenced an
investigation into the death of David Andrew Llewellyn O’Garro, aged 34
years.
The investigation concluded at the end of the inquest on 13 June 2014. I
made a narrative determination, attached.
4
CIRCUMSTANCES OF THE DEATH
Mr O’Garro suffered a sudden death in epilepsy. At the time of his death,
he occupied a single cell at HMP Pentonville, and so nobody was with
him to raise the alarm when he suffered what is likely to have been a final
seizure.
1
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.
The nurse who carried out the first reception screen of Mr O’Garro did not
complete a cell sharing risk assessment (CSRA) indicating that he should
share a cell, though she told me she knew that a person with epilepsy
should not occupy a cell alone. She completed the computer record
indicating that he was fit for any cell occupancy.
No HMP Pentonville CSRA was ever found for Mr O’Garro.
During the inquest:
- one prison nurse appeared at times completely unfamiliar with the
CSRA, and wholly unclear as to how to ensure (in 2012 or now)
that prisoners with epilepsy would have a cellmate;
- a prison doctor said that a locum doctor working at the prison
might not even complete a CSRA because s/he would not know
how the prison works;
- one of the prison officers was unsure how a message from
healthcare regarding cell sharing would reach any particular officer
if s/he was away on the day it was entered into the observation
book.
Whilst I appreciate that you are making significant changes to the
reception process for new prisoners, there appeared at inquest to be a
lack of clarity and shared understanding among those working at HMP
Pentonville.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and the healthcare providers for HMP Pentonville 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 13 August 2014. I, the coroner, may extend the
period.
2
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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
HM Inspectorate of Prisons
National Offender Management Service
David O’Garro’s auntie
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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
16.06.14
3
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