Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0446, written 15 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 | 15 Oct 2014 |
|---|---|
| Reference | 2014-0446 |
| Deceased | Seweryn Glowinski |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
ANNEX A 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. HMP Long Lartin 2. 3 1 | CORONER | am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire 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. 3 | INVESTIGATION and INQUEST Ong" July 2013 | commenced an investigation into the death of Seweryn Witold Glowinski then aged 25 years. The investigation concluded at the end of the inquest on 15" October 2014. The conclusion of the inquest was a narrative conclusion the medical cause of death being hanging . 4 | CIRCUMSTANCES OF THE DEATH Mr Glowinski was a serving prisoner at HMP Long Lartin in Worcestershire. He was diagnoised with paranoid schizophrenia and for his own protection was transferred from normal focation into the segregation wing. Although it was anticipated he would only be on segregation for a matter of days he stayed there for a little under a fortnight. He was found hanging in his cell on the evening of 3° July 2013, Mr Glowinski was the subject of an open ACCT because of self-harm. 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) There appeared to be no communication between the Residential Wing and the Segregation Unit as to the plan for Mr Glowinski. It appeared that the Segregation staff were unaware that the wing staff wanted to have him risk assessed for a move to another location and in fact the risk assessment was not commenced until the day before his death. (2) The documents to review and authorise his further detention in the Segregation Unit were completed by the way of “cutting and pasting” from other prisoner's files. It was clear that the information on Mr Glowinski's paperwork was incorrect and had been transposed from another prisoner, (3) The Senior Custodial Managers in the wing were unaware of the requirements of Prison service orders which meant that an individual on an open ACCT should not be transferred to segregation unless there were exceptional reasons for doing so. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action, ie 1. To consider whether the purpose and plan for a man being sent to segregation should be communicated to the Segregation Unit and the Rule 45 Board which meets there. 2. To prohibit the practice of cutting and pasting information from other prisoners files. 3. To ensure that Senior Officers and Custodial Manager are aware of the terms of the relevant prison service orders. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10" December 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 , the family and the Healthcare Trust Chief Executive . 1am 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. Signed GU Williams 15th day of October 2014 H M Senior Coroner :
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