Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0438, written 9 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Oct 2014 |
|---|---|
| Reference | 2014-0438 |
| Deceased | Vincent Oliver |
| Coroner | Tony Brown |
| Coroner area | North Northumberland |
| 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.
Tony Brown LLM
H M Senior Coroner
North Northumberland
Teleph
17 Church Street
Berwick-upon-Tweed
TD15 1EE
Tel : 01289 304318
Fax : 01289 303591
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Mr Matt Spencer
Director
HMP Northumberland
Acklington
Morpeth
Northumberland
1
CORONER
I am Tony Brown, senior coroner, for the coroner area of North Northumberland
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 4th July 2013 I commenced an investigation into the death of Vincent Oliver, age 50
years. The investigation concluded at the end of the inquest on 29th September 2014.
The conclusion of the inquest was that Vincent Oliver died from natural causes, the
medical cause of death being:-
1a Ischaemic Heart Disease
1b Coronary Artery Atheroma
4
CIRCUMSTANCES OF THE DEATH
Vincent Oliver was serving a term of imprisonment at HMP Northumberland. A roll
check was carried out at 4.00 p.m. on 4th July 2013 and Mr Oliver was recorded as
present. At approximately 5.40 p.m., shortly after the cells were unlocked, the lifeless
body of Vincent Oliver was discovered in his cell by a fellow prisoner.
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 prison officer unlocking Mr Oliver’s cell on 4th July 2013 at approximately 5.40 p.m.
for the evening meal did not check on his physical well-being by getting a response from
him, before moving on to the next cell. This led to Mr Oliver, who had died some time
earlier and was affected by rigor mortis, being found by another prisoner when he
entered Mr Oliver’s cell.
There has been a number of other occasions at the prison when appropriate cell
unlocking procedures have not been followed and the Prisons and Probation
Ombudsman has made recommendations about this previously.
I understand that a Prison Director’s Order has been issued requiring that on roll check
Prison Officers must obtain a response from each prisoner to ensure their physical
presence and well-being. My understanding of the procedures is that there is no current
requirement for the Officer completing the roll check to record on the roll check report
that he or she has complied with the requirements of the above Order.
6
ACTION SHOULD BE TAKEN
In my opinion 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 5th December 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,
and the Treasury Solicitor’s Department.
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
DATE 09 October 2014
TONY BROWN
HM Senior Coroner for North Northumberland
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.
a Equality, Rights and Decency National Offender Group H National Offender Management Service Management Service 4th Floor, Clive House, 70 Petty France, London, SW1H 9HD ri Mr Tony Brown LLM HM Senior Coroner North Northumberland 17 Church Street Berwick-Upon-Tweed TD15 1EE December 2014 Dear Mr Brown, Regulation 28 Report concerning the inquest into the death of Vincent Oliver on 4" July 2013 at HMP Birmingham Thank you for your report addressed to the Director dated 9 October concerning the inquest into the death of Vincent Oliver who died at HMP Northumberland on 4" July 2013. Your letter has been passed to Equality, Rights and Decency Group in the National Offender Management Service (NOMS), to respond to as we are responsible for the policy on suicide prevention and self- harm management and for sharing learning from deaths in custody. You raised concerns at the inquest about staff receiving responses from prisoners when they are unlocked. PSI 75/2011 Residential Services at chapter 2.3 offers the following guidance, “The appropriate arrangements will depend on the local regime, but there need to be clearly understood systems in place for staff to assure themselves of the well being of prisoners during or shortly after unlock. For example, if a prisoner is expected to leave their cell for an activity shortly after being unlocked, then it will be sufficient for there to be a check on any prisoner who does not do so. Where prisoners are not necessarily expected to leave their cell, staff will need to check on their well-being, for example by obtaining a response during the unlock process.” In order to address this issue HMPS Northumberland have introduced a system for recording in writing that wellbeing checks of prisoners have taken place throughout the day. The wing diaries have been amended to reflect the change and the system was in place from Sunday 16" November 2014. | attach copies of the relevant Director's Order and Notice to Prisoners. Yours sincerely aral naerson NOMS Equality, Rights and Decency Group
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