Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0381, written 8 Aug 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Aug 2014 |
|---|---|
| Reference | 2014-0381 |
| Deceased | Sean Brock |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| Category | State Custody related deaths |
| Organisation named | Central and North West London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Sean Robert BROCK 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. Mr. Andrew Selous MP, Minister for Prisons Service. 102 Petty France London SW1H 9AJ 1 | CORONER lam Mr. Tom Osborne senior coroner, for the coroner area of Milton Keynes 2 | CORONER’S LEGAL POWERS | 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Awww_legislation.gov.uk/uksi/2013/1629/part/7/made [3 | INVESTIGATION and INQUEST On 14" November 2013 | commenced an investigation into the death of Sean Robert Brock aged 21 years. The investigation concluded at the end of the inquest on 6th June 2014. The conclusion of the inquest sitting with a jury was that of suicide, the medical cause of death being hanging. The circumstances are: a) That this was Sean's first time at an adult high security prison b) That he died on his fourth day in prison. 4 | CIRCUMSTANCES OF THE DEATH Sean Brock died by hanging in cell 220, house unit 1B, Woodhill Prison, Milton Keynes. He was pronounced dead at 11:11 a.m. on Sunday 10 November 2013. 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. — A Governor from the prison during his evidence informed me that the number of prison officers at HMP Woodhill had been reduced by one third. The reduction in numbers will in his view compromise prisoner safety and may put prisoner lives at risk. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28" October 2014. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- Family Prison and Probation Ombudsman Treasury Solicitor Central and North West London NHS Foundation Trust GEOAmey | am also under a duty to send the Chief Coroner a Copy of your response.
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.
ea M i n j st ry of National Offender Management Service Offender Safety, Rights & Responsibilities Group. J U ST [ C E 4" Floor (post point 4.12), Clive House National Offender 70 Petty France Management Service London SW1H 9HD Mr Tom Osborne HM Senior Coroner for Milton Keynes 20 October 2014 Dear Mr Osborne, Thank you for your Regulation 28 Report to Prevent a Future Death dated 8 August 2014 and addressed to Andrew Selous, Minister for Prisons, concerning the recent inquest into the death of Sean Robert Brock at HMP Woodhill on 10 November 2013. Your letter has been passed to Equality, Rights and Decency (ERD) Group, which forms part of the national Management Service (NOMS), as we have the policy responsibility for suicide prevention and self-harm management, and for sharing learning fram deaths in custody. | am responding on behalf of NOMS. In your report you raised your concern that a Governor's evidence reported that the number of prison officers at HMP Woodhill had been reduced by one third, and his concern that this would impact on prisoner safety and may put prisoner lives at risk. HMP Woodhill is managed within the High Security estate and despite some reduction in staff numbers the current identified total staffing forecast includes an agreed complement of Officers that are necessary to provide safe decent and secure conditions. Included within the staffing forecast are staff specifically appointed to first night procedures, prison induction and safer custody work. HMP Woodhill has a Senior Manager who is responsible for safer prisons and equalities, and a Custodial Manager responsible for the management of safer custody procedures. You may be aware that all public sector prisons have been subject to “benchmarking” which involved a team visiting each prison and benchmarking staff-to-prisoner ratios for a wing or for a workplace. This process required establishing a safe, decent and secure operating level in agreement with the governor and the senior team. Negotiations with staff associations were also held. HMP Woodhill received its "New ways of working" report in August this year. This report set out the agreed staffing headcount. It is recognised that HMP Woodhill is currently experiencing a high number of vacancies across all grades. This is being addressed via local and national recruitment drives along with staff working at HMP Woodhill on detached duty. | would like to reassure you that HMP Woodhill is working hard to ensure that key information is shared between prison staff and contractors in delivery of safety for all prisoners currently in its care and all staff are aware of the importance of safer custody. | hope that you find this information helpful. Yours sincerel
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