Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0552, written 18 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 | 18 Dec 2014 |
|---|---|
| Reference | 2014-0552 |
| Deceased | John Stabler |
| Coroner | Stuart Fisher |
| Coroner area | Lincolnshire (Central) |
| Category | State Custody related deaths |
| Organisation named | Nottinghamshire Healthcare NHS Foundation Trust |
| 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.
HM CORONER Central Lincolnshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS. REPORT IS BEING SENT TO: 1 : Director of Public Sector Prisons, NOMS 2 overnor HMP North Sea Camp 3. ES Governor HMP Lincoln 4. The Director, NHS England 5. The Director, Nottoghenushire Healthcare NHS Trust CORONER lam Stuart P G Fisher, Senior Coroner, for the coroner area of Central Lincolnshire, Lindum House, 10 Queen Street, Spilsby, Lincolnshire, PE23 5JE. 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 13 March 2013 | commenced an investigation into the death of John Derek Stabler, aged 55 years. The investigation concluded at the end of the inquest on 17 October 2014 The Jury returned a conclusion that 'He killed himself’ The medical cause of death being : 1a. Hanging CIRCUMSTANCES OF THE DEATH At 0100 hours on 4 March 2013 the deceased. was found hanging in cell D1.5 in HMP Eincoln: He was taken to Lincoln County Hospital where he died on 6 March 2013. He was serving an indeterminate sentence, was an inmate at HMP North Sea Camp where he had a history of mental health problems. He was transferred to HMP Lincoln on 1 March 2013 and was found hanging (though not deceased) in a cell on the Segregation Wing on 4 March 2013. He was taken to Lincoln County Hospital where he died on 6 March 2013. 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. — ()) That there is a need for the Prisoner Escort Record to be reviewed and redesigned (II) The requirements for System 1 (Medical Records) to be made available in Reception at HMP North Sea Camp and in The Care and Reception Unit at HMP Lincoln ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation have the power to take such action. q) Director Public Sector Prisons, NOMS (2) Governor HMP North Sea Camp (3) EY Governor HMP Lincoln (4) The Director, NHS England (5) The Director, Nottinghamshire Healthcare NHS Trust YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 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 and to the following : (1) Deighton Pierce Glynn (2) Treasury Solicitors | 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 publicati Our fesponse by the Chief Coroner. SPG FISHER * Senior Coroner for Central Lincolnshire Area
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