Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0528, written 5 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Dec 2014 |
|---|---|
| Reference | 2014-0528 |
| Deceased | Peter Mackie |
| Coroner | Richard Hulett |
| Coroner area | Buckinghamshire |
| Category | State Custody related deaths |
| 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.
Coroner for Buckinghamshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: P| Governing Governor Springhill Prison CORONER 1 am Richard Alexander Hulett, Senior Coroner for Buckinghamshire 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. INVESTIGATION and INQUEST On 03/01/2014 | commenced an investigation into the death of Peter Harry Mackie, 42 . The investigation concluded at the end of the Inquest heard from 24" November to 1 December 2014, The Conclusion was that “ He took his own life, whilst the balance of his mind was disturbed. Between 14:51 and 15:08 on Saturday 28th December 2013, the deceased hanged himself in the chapel at HMP Springhill. “ CIRCUMSTANCES OF THE DEATH At about 1545 hours on Saturday 28th December 2013 Police received a call from staff at the prison to say that a male was hanging (deceased) in the chapel. An air ambulance had been called and he had been declared life extinct at 1536 hours by | The circumstances around Peter MACKIE - He was currently at Springhill Prison serving a life sentence for possession of an imitation firearm and robbery in 2001. He had been there for about 4 months after being at different category prisons. After lunch on the 28th December Mr Mackie went and spoke to another inmate outside his hut. Mr MACKIE asked him to go to the chapel and the other inmate thought he looked upset .They walked over to the centre and asked prison staff to let them in to the main building where the chapel was located. At the same time another inmate came over and went into the chapel with them .The first inmate recalls that Mr MACKIE stated that he was upset, he mentioned that it was the anniversary of his mother’s death (1 year) and he had never been told about the funeral therefore he never went. He also mentioned that he owed money but this has not been confirmed. They remained within the chapel for about an hour and the second inmate was looking through the Bible and reading out verses to try and help Mr MACKIE .The first inmate thought that after that hour Mr MACKIE was a lot better. He also mentioned that he thought Mr MACKIE was dressed very smartly as if he was in his best clothes. They all left and the first inmate recalls Mr MACKIE asking him to return to the chapel in about half an hour's time. He thought that Mr MACKIE was ok and had other things to do so forgot to go back .At around 1500 hours a third inmate returned to the prison after having leave over the Christmas period. From reception he went straight to the chapel as he spends a lot of time there due to his religious beliefs. He went straight through the unlocked door, up the stairs and then saw a male hanging. Initially he thought it was a prank as he had never seen anything like it before. He then approached Mr MACKIE to get him down and realised that he could not therefore he ran back to the reception and told 2 prison staff. .Ail three ran to the chapel. One of the officers held the legs and the prisoner used a” fishknife” to cut Mr MACKIE down. No CPR was performed. 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 Coroner's Court, 29 Windsor End, Beaconsfield, Buckinghamshire, HP9 253 Tel 1494 475505 | Fax 01494 673760 The MATTERS OF CONCERN are as follows. — (1) Despite improvements during 2014 concerns remain as to the overall numbers of first aiders available on the Springhill site at any time including at night. A first aider on the Grendon site is unlikely to be able to respond in time due necessary security moving from a closed estate to an open prison. This applies in respect of those trained to “First aid at work (FAW) and Emergency First aid at work (EFAW). Operational needs may deplete numbers with FAW and/or EFAW by transferring them to the closed part of the overail site. (2)There are usually two contracted healthcare staff available during daytimes but they work together and are therefore either on one site or the other. There are inevitable security delays in moving between the two prisons and the possibility of splitting this cover was raised in the evidence. (3)It appears that there is not currently any guidance to staff as to when CPR should be commenced. This applies to CPR trained staff. For those without such training there is a lack of clarity as to what if any action they should undertake. The Coroner's Court, 29 Windsor End, Beaconsfield, Buckinghamshire, HP9 2S Tel 04494 475505 | Fax 01494 673760 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 January 2015, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons me: Mitchell Solicitors, representing cousin of the deceased) (sister of the deceased) a (SOL) ME Care UK) tam 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, Dated 5 December 2014 Signature. ===" Senior Coroner for Buckinghamshire The Coroner's Court, 29 Windsor End, Beaconsfield, Buckinghamshire, HP9 233 Tel 01494 475505 | Fax 61494 673760
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.
ae Equality, Rights and Decency Group . National Offender Management Service National Offender . 4th Floor, Clive House, Management Service 70 Petty France, London, SW1H 9HD Richard Alexander Hulett Senior Coroner Buckinghamshire 27 January 2015 Dear Mr Hulett, Thank you for your Regulation 28 Report of 5 December 2014 addressed to the Governing Governor of HMP Grendon and Springhill, following the recent inquest into the death of Peter Harry Mackie at Springhill on 28 December 2013. Your report has been passed to Equality, Rights and Decency Group in the National Offender Management Service (NOMS), as we have the policy responsibility for suicide prevention and self-harm management, and for sharing learning from deaths in custody. This response has been provided on behalf of the Governing Governor of HMP Grendon and Springhill and we are responding to the concerns you have raised in your report as follows: Number of first aiders available on the Springhill site especially at night HMP Grendon and Springhill are currently working on increasing the number of trained first aid staff at both establishments to First Aid at work (FAW) and Emergency First Aid at Work (EFAW) level. A number of staff were trained to these levels during 2014 but it is recognised that more are needed at the Springhill site to provide cover, especially at night when healthcare staff are located at Grendon. A new risk assessment is being completed to ensure appropriate levels of staff are identified to provide 24 hour cover. This system will be fully operational within 12 months Contracted healthcare staff available on the Springhill site Two healthcare staff are currently contracted to work in Grendon at weekends during the day to provide cover and to facilitate clinics. The shortage of healthcare staff at HMP Springhill has been fed back by the prison to the NHS Commissioners who are responsible for funding and commissioning healthcare services. Any risks in the meantime, due to shortage of healthcare staff at HMP Springhill will be mitigated by the implementation of first aid trained staff on each site to bridge the gap between incident and healthcare staff arriving at the incident. Guidance to Cardiopulmonary Resuscitation (CPR) trained prison staff_at HMP Grendon and Springhill as to when CPR should be commenced All prison staff who are trained and qualified as first Aiders have undertaken a first aid at work training course, at either the higher level (First Aid at Work course) or the lower level (Emergency First Aid at Work), as required by the Health and Safety (First Aid at Work Regulations) 1981. CPR training forms a fundamental aspect of each of these training courses. All first aid trained staff will be aware of how and when to apply CPR following the training they receive. A review of the First Aid PSI is currently taking place. Once the period of consultation is complete, a revised PSI will be published. During the interim period, NOMS has issued the old First Aid Guidance for staff to use, as attached. HMP Grendon and Springhill have sought additional advice from the Resuscitation Council UK on when CPR should be commenced and will be providing staff who work at HMP Grendon and Springhill with written advice on what to do should they find somebody not breathing. This will be provided to all staff in the form of a booklet by 31 January 2015, to ensure staff receive this information. The information will form part of the induction for new staff and will be made available on the local intranet at HMP Grendon and Springhill. | hope this provides assurance that the specific issues identified in this case, both at the inquest and by the Prisons and Probation Ombudsman, are being addressed. Yours sincerel MS Equality, Rights and Decency Group
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