Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0540, written 17 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 | 17 Dec 2014 |
|---|---|
| Reference | 2014-0540 |
| Deceased | Connor Smith |
| Coroner | Andre Rebello |
| Coroner area | Liverpool |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
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: Rt Hon Chris Grayling MP Michael Spurr Nigel Newcomen CBE Secretary of State for Justice Chief Executive Prisons & Probation Ombudsman 102 Petty France NOMS P O Box 70769 London SW1H 4" Floor London 70 Petty France SE1P 4xXY London 1 | CORONER | am André Rebello, Senior Coroner, for the area of Liverpool 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 On 7th January 2013 | commenced an investigation into the death of Connor Steven Paul SMITH, Aged 20. The investigation concluded at the end of the inquest on 16th December 2014. The conclusion of the inquest was la Hanging Connor Steven Paul Smith died of an inadvertent consequence of a deliberate act, where the intentions were unclear, in the early hours of 2nd January 2013. From all the evidence heard, Mr Smith gave no indication of presenting a risk of immediate suicide. All of those who gave evidence who knew Mr Smith, both professionally and personally, were shocked to learn of his death. 4 | CIRCUMSTANCES OF THE DEATH Connor Smith was a 20yr old male who had been in custody at HMP Altcourse since November 2012. On 29.12.12 there was an altercation in the prison with another inmate. The inmate was allegedly assaulted by four males including Connor. As a result Connor was moved to another cell where he was the sole occupant. The assault has now been denied by the victim. On_01.01.2013 Connor was seen alive and well by prison custody fice who had several conversations with him. She said he did not appear down in the dumps or depressed. A head count at 20:30hrs accounted for Connor. The next morning at approx 05:18, PCOS conducted cell checks. CCTV has shown PCO look through the cell hatch and discover Connor hanging from a bed sheet. Other officers -attend as well as paramedics and resuscitation is carried out unsuccessfully. There were no provisions in place that required Connor to be checked on more than any other prisoner. Within his prison records, there are two entries to suggest previous self harm. The first in 2005/6 when he tried to cut his wrists, the second was in 2012 with an attempted overdose. 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. — On the 28" January 2013 the PPO investigator interviewed a PCO with regard to a review hearing under rule 49 — colloquially known as a rule 45 board. The Officer was asked about the record of the meeting in which his name had appeared as an attendee. Given the frequency of such meetings the officer could not remember the meeting on the 1% January 2013 but was interviewed about it creating a 15 page transcript. On examination of other witnesses, other documentary evidence and a video of the meeting made it clear that the PCO was not present at the review hearing — his name had been entered on the Segregation Rule 45/Rule 49 Authority for continued segregation before the meeting but he had not been there. This is an area of concern highlighting the quality of the investigation by the PPO where by such an error could in another case prevent lessons from being learnt. (Documentation is provided to the PPO alone to assist with response to avoid publication of this report being redacted) 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 10th February 2015. |, 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. | have sent a copy of my report to the Harris Review which has expressed an interest HMP Altcourse The family of Mr. Smith | 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. ose André Rebello. Senior Coroner for the City of Liverpool Dated: 17" December 2014
2 responses 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.
Ministry of rer Equality, Rights and Decency Group J U ST | C & National Offender Management Service 4th Floor, 70 Petty France, London SW1H 9EX National Offender Management Service be ae Mr A Rebello OBE Senior Coroner H M Coroner’s Court Gerard Majella Courthouse Boundary Street Liverpool L5 2QD 6 February 2015 Dear Mr Rebello Thank you for your Regulation 28 report dated 17 December 2104 addressed to the Secretary of State for Justice and to Michael Spurr, Chief Executive of the National Offender Management Service (NOMS) concerning the recent inquest into the death of Connor Smith on 2 January 2103. Your letter has been passed to the Equality, Rights and Decency Group in NOMS as we have responsibility for policy on suicide prevention and self harm management and for sharing learning from deaths in custody. | understand that your concern relates to the quality of the investigation by the Prisons and Probation Ombudsman. However in raising that concern you have drawn attention to the fact that a member of staff was recorded as having attended a meeting at which he was not present, and | would like to provide reassurance that this issue has been addressed by the Director of HMP Altcourse. A notice has been issued to all senior managers who chair Segregation Review Boards advising them that the documentation for completion at the meeting must not have names entered in advance and that it is their responsibility to check that attendance at the meeting is correctly recorded. | hope that you find this information helpful. Yours Sincerely
PRISONS AND PROBATION OMBUDSMAN |[®& for England and Wales Independent Investigations Mr Andre Rebello Your ref: Po Senior Coroner for the City of Liverpool HM._-Coroner’s Court Gerard Majella Courthouse Boundary Street Liverpool L5 2QD RECEIVED - 7 FEB 2015 | | iM. CORONER } 30 January 2015 Dear Mr Rebello, Re: Regulation 28 report concerning the inquest into the death of Mr Connor Smith at HMP Altcourse on 2 January 2013 Thank you for:your regulation 28 report of 17 December 2014, addressed to Nigel Newcomen, the Prisons and Probation Ombudsman, about the inquest into the death of Mr Connor Smith at HMP Altcourse on 2 January 2013. | am responding, as the Deputy Ombudsman responsible for investigations into deaths in custody. Your report identified an apparent minor factual inaccuracy in the PPO report, in that the inquest heard evidence that an officer who was listed as being present at a segregation review, and told the PPO investigator that he was present, appears not to have attended the meeting after all. During our investigation, no other attendees listed as being present at the meeting, said that the officer was not there and no one from the prison corrected this when the draft report went to them for fact check. While obviously, we would prefer our reports to be entirely accurate, in these circumstances, this was the responsibility of. the officer and the prison. There was no reason for the investigator to disbelieve the evidence at the time. | understand the officer did not give evidence at the inquest, but when interviewed, he told the investigator several times that he was at the review. We regard the apparent inaccuracy as minor, as we took no account of the officer's evidence about the review in reaching our conclusions and we consider it had no material bearing on the circumstances of Mr Smith’s death. As you know, this office is fully committed to helping avoid any future deaths in custody, but | am not clear how we can take any action in relation to the matter you identify which might. help avoid any future fatality, which is the avowed purpose of regulation 28 reports. Ultimately, the services we investigate are responsible for safeguarding those in custody. We can only realistically contribute to preventing a reoccurrence of the circumstances. of Mr Smith’s death through the recommendations made in our investigation reports. For that reason, the memorandum of understanding between the PPO and the Coroners’ Society recognises that because of our role it ‘would be unusual for the conduct of the investigation by the PPO to come within [a Regulation 28} report’. PO Box 70769, London, SE1P 4XY Tel: ee E-mail: mail@ppo.gsi.gov.uk www.ppo.gov.uk In the sad circumstances of Mr Smith’s death, the Ombudsman made four recommendations to the prison about assessment and management of depression, the operation of the Incentives and Earned Privileges scheme for people on basic, healthcare input into decisions about segregation and investigations into allegations about bullying, which we hope might help prevent future similar deaths. | do not believe there is further specific action that the PPO can take. Yours sincerely Deputy Prisons and Probation Ombudsman cc: Rt Hon Chris Grayling MP - Secretary of State for Justice His Honour Judge Peter Thornton QC, Chief Coroner Michael Spurr — Chief Executive - NOMS Lord Toby Harris — Chair of Independent Panel on Deaths in Custody Family of Mr Smith Mr Bob McColm — Director —- HMP Altcourse
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