Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0568, written 30 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 May 2014 |
|---|---|
| Reference | 2014-0568 |
| Deceased | Matthew Purser |
| Coroner | Philip Rogers |
| Coroner area | Swansea Neath & Port Talbot |
| 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.
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: MINISTRY OF JUSTICE
1. The Chief Executive, NOMS,
2. The Governor, H.M. Prison Swansea
3
1 CORONER
lam PHILIP ROGERS Senior Coroner, for the coroner area of Swansea and Neath Port
Talbot
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 21% June 2012 | commenced an investigation into the death of Matthew Thomas
Purser aged 29. The investigation concluded at the end of the inquest on 24" of
February 2014. The conclusion of the inquest was a Narrative conclusion. The cause of
death as given by the Pathologist was:
1a) Hanging
A summary of the Narrative conclusion of the Jury is that the deceased took his own life
by hanging himself on 13” June 2012 at H.M. Prison Swansea.
The deceased intended to take his own life due to contributory factors of severe
depression and relationship breakdown.
ACCT reviews should have taken place after incidents at noon and 4 pm on 13" June
2012 and the sharing of information between prison staff by way of recording significant
interactions in the ongoing record of the ACCT plan were inadequate. However, these
matters were not considered to have more than minimally contributed to the deceased’s
death.
4 | CIRCUMSTANCES OF THE DEATH
Matthew Purser hanged himself in his cell at Swansea Prison about 7.25 pm on 13"
June 2012. He had been on remand from 9" June 2012 and was in the drug recovery
wing because of his substance misuse. He was receiving medication for alcohol
withdrawal and had been placed on an ACCT (self harm monitoring document) from the
time of his initial assessment by a Nurse on arrival at the Prison. At this initial
assessment Mr. Purser referred to recent bereavement, attempted self harm about three
weeks before and very high alcohol intake. He stated he was hearing voices and that
he had an appointment later that month in the community with a psychiatrist. He was
given anti withdrawal medication and a referral was made by the Nurse to the in-reach
mental health team ie. the Local Health Board ran secondary mental health service
working in the prison.
Under the ACCT observations were set at two hourly in the day, with three meaningful
conversations to be conducted.
On the following day a second health screen was carried out involving seeing the prison
GP and a mental health nurse on two occasions. Mr. Purser was booked into the
“lighthouse clinic” (primary care prison mental health service). On the same day the
deceased underwent his ACCT assessment and first ACCT review. The triggers for
further review were recorded as "loss of contact with partner/breakdown in relationship”.
During the assessment interview for the ACCT the deceased had shown himself to be
very dependent on being able to speak to his partner and the prison tried to facilitate this
contact with one of the officers ringing the partner on that day to give her information
about visiting and after which the deceased was said to be much improved in mood.
Mr. Purser continued to have telephone contact with his partner on 11" and 12" June
but on 13" June in a telephone call to her shortly before midday he was seen by officers
to become visibly upset and was noticed punching the metal hood over the telephone.
An officer who witnessed this took the Mr. Purser to an interview room to calm him
down. An entry was made at midday on the ACCT that Mr. Purser had stated his
girlfriend had had a miscarriage and wanted to leave him. The officer said that he would
see Mr. Purser after the lunch break and at 2.30 pm he took him to a staffroom and rang
the partner on behalf of Mr. Purser, saying that Mr. Purser was sorry to put pressure on
her and that Mr. Purser would not telephone her again for 24 hours as the calls were
upsetting them both. After this Mr. Purser seemed more settled. No entry was made in
the ACCT concerning the interaction of the officer and Mr. Purser after lunch. Despite
the agreement which the officer had reached between Mr. Purser and his partner Mr.
Purser telephoned her again at about 3.50 pm. The same officers saw Mr. Pursher on
the telephone and when challenged he said he was calling his mother but one of the
officers asked control to check the number called and was told it was the partner. An
ACCT entry was made at 4 pm stating that Mr. Purser was a manipulative individual,
willing to say anything to get his own way, but the officer who had made the agreement
with the partner did not challenge him about his behaviour and decided to leave
speaking to him until the next day.
After 6 pm there were two further telephone calls between Mr. Purser and his partner in
which they argued and he threatened to hang himself. These were not observed by
officers. At about 6.35 pm Mr. Purser asked to go back into his cell to use the toilet. The
officer who allowed this had no concerns about his demeanour although his cell mate
said he was very upset. At about 7.25 pm the same officer noticed the observation
hatch covered and on investigating found Mr. Purser hanging. This was about twenty
five minutes after he was last observed.
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. The Doctor who saw Mr. Purser for the second health screen on the day after
admission had not received ACCT training as required by PS1 64/2011 and
HMP Swansea Suicide Prevention Policy 2010 and was not aware of the
requirement for him to be trained in the procedures although he was aware of
the procedures.
2. The trigger event endorsed on the documentation requiring review of Mr. Purser
under the ACCT was given as “loss of contact with partner/breakdown in
relationship’. Mr. Purser’s apparent dependence on maintaining contact with his
partner was correctly identified by the prison but the way in which the wording of
the trigger was expressed left much to the subjective assessment of the officers
about the state of his relationship with his partner. Because of the way in which
the ACCT records were kept officers did not have enough information to make a
realistic assessment and in their evidence some officers draw a distinction
between Mr. Purser’s relationship going through a difficult time and it having
broken down. Ifa trigger event is something which cannot be easily and
objectively determined by an officer more detailed observations and recording
will be required. If the only way in which a trigger can be expressed is in similar
language to this case some indication needs to be given as to how the
assessment is to be carried out and how clearly information must be shared by
means of the records kept.
3. The prison appreciated that Mr. Purser was due to have a psychiatrist's
appointment in the community soon after coming into prison. Although he was
booked into the primary care prison mental health service the means by which
community health records were to be obtained was not clear. For an
appropriate assessment to be made there is a need for an urgent contact with
community mental health services to be made so that records are promptly
obtained.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 25" July, 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
Perso
lam 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.
30" May 2014
ZBL an weld, Philip Rogers
dl Senior Coroner
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