Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0576, written 21 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jul 2014 |
|---|---|
| Reference | 2014-0576 |
| Deceased | Marcin Stoga |
| Coroner | Darren Salter |
| Coroner area | Oxfordshire |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. f | Governor of HMP Bullingdon
It is envisaged that the Governor will liaise with the Head of Healthcare.
1
CORONER
lam Mr D M Salter, Senior Coroner, for the coroner area of Oxfordshire.
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) Reguiations 2013.
INVESTIGATION and INQUEST
in April 2013 | commenced an Investigation and then opened an Inquest on 2 May 2013
into the death of Marcin Jacek STOGA, aged 27, who died on 24 April 2013 at HMP
Bullingdon. | concluded the case at Inquest on 30 June 2014 at Oxford Coroner's Court.
As it was a death in custody, it was a jury Inquest. A copy of the Record of Inquest
completed by the jury is attached.
It wilf be seen that the jury gave a narrative verdict which confirmed that Mr Stoga
committed suicide but went on to say that in the jury’s view there were missed
opportunities to support the prisoner which were of a systemic nature.
| Members ison and Healthcare gave oral evidence as did Deputy
Governor | anticipate that you will have received a report about the
Inquest.
| CIRCUMSTANCES OF THE DEATH
The circumstances are of course known to you but, briefly, Marcin Stoga had been at
Bullingdon Prison since November 2012 on remand. The main charge against him was
the attempted rape of a prostitute and, if convicted, he could expect a lengthy prison |
sentence. It was his first time in a UK prison. He spoke {ittle English. He had been to
| court on 23 April which is the day before his death. It is believed he was due to return to
| court at the end of April. He was found hanging in his cell on the afternoon of 24 April.
{ have not provided you with a copy of the Inquest file because the file was disclosed to
the prison/ Treasury Solicitors prior to Inquest.
CORONER'S CONCERNS
During the course of the Inquest the evidence revealed matters giving mse to concerns. |
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 make this report to you.
The MATTERS OF CONCERN are as follows:
(1) Prior to Mr Stoga’s arrival at HMP Bullingdon, there was a Prisoner Escort Record
which referred to the fact that Mr Stoga had taken an overdose in 2012. it appears that |
this form and this information was not available to the Prison Officers or the Healthcare
Nurse who initially assessed Mr Stoga upon his arrival. One would have thought that the
form or at feast the information on the form should routinely be available to those
responsible for carrying out initial assessments of this nature.
(2) A second concern, which is to some degree related ta the first, is the fact that
prisoners (particularly those with mental health difficulties or who are otherwise at a
medium/high risk of self-harm) are not routinely assessed on return from court hearings
Mr Stoga attended court on 7 December 2012 and again on 11 February 2013 and 23
April 2013, the day before his death. There were no such assessments. On this last
occasion it is believed that Mr Stoga was charged with assaulting his partner.
| understand from evidence and information at Inquest that there has been a review (and
that this issue also formed part of the PPO Recommendations) and that persons |
returning from court will be seen by the Duty Reception Nurse to ascertain any change |
in circumstances. What is not clear is if this is anything other than a cursory assessment.
It appears that a more thorough assessment is likely to be required for those prisoners
whe have a history of mental health issues and are believed to be at a medium/high risk
of self-harm or suicide. It appears there may be a need for some written guidance for
staff or perhaps a protocol.
i appreciate that the two concerns | have outlined are partly within the responsibility of
prison staff and partly that of Healthcare staff. Consequently, | anticipate it will be
necessary for you to liaise with the Head of Healthcare. It seems to me however that
overall responsibility for the safety of prisoners rests with the Governor and HM Prison
Service.
| ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and 1 believe that 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. |
may extend the period on request.
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 [nterested Persons.
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, at the time of your response, about |
the release or the publication of your response by the Chief Coroner.
x I MONDAY 21 JULY 2014 |
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.
GR (FORUSAIRE National Offender Management Service Ministj yo ORONERS OFFICE Offender Safety, Rights & Responsibilities JUS ic = 5 JAN 15 ? GOs eat point 4.12), Clive House Petty France oe SW1H 9HD National Offender Management Service _ TprcENiO.n- a Mr DM Salter Senior Coroner for Oxfordshire 29 December 2014 Dear Mr Salter, Thank you for your letter dated 21 July addressed to lan Young, Governor of HMP Bullingdon, concerning the inquest into the death of Marcin Stoga at Bullingdon on 24 April 2013. Your letter has been passed to Equality, Rights and Decency (ERD) Group, part of the National Management Service (NOMS), as we have responsible for policy on suicide prevention and self-harm management, and for sharing learning from deaths in custody. Please accept my sincere apologies for the delay in responding to this letter. Unfortunately your letter was not received at HMP Bullingdon until 30 September and although | understand the Treasury Solicitor contacted your office to say that a response would be sent as soon as possible, this did not happen. | am very sorry that | have not been able to send you a reply before now. In your Regulation 28 report, you expressed your concern that on Mr Stoga’s arrival at HMP Bullingdon, the Prisoner Escort Record (PER) was not shared with prison officers or healthcare staff who initially interviewed and assessed Mr Stoga. The PER is the key document for ensuring that information about the risks posed to and by prisoners on external movement from prisons or transferred within the criminal justice system is available to those responsible for their custody. | am aware that you invited submissions on your draft Regulation 28 report to which the Treasury Solicitor responded on 18 July confirming that since the inquest into the death of Mr Stoga, the Deputy Governor had put in place a checklist to assist in the assessment of risk of self-harm and suicide. This checklist is completed by the Reception Receiving Officer and a healthcare professional when a prisoner returns fon eoutt and acknowledges any risk information received, for example the ae Es t e cise was Being piloted at the prison, and} You will, | am sure be interested to know that a Pilot Regional PER forum has met twice in the second part of this year at HMP Winchester attended by a wide range of key stakeholders and operational practitioners. The forums remit is to consider and develop improvements to the PER whilst addressing the recommendations from the HMIP Thematic Review and related ones from the independent Police Complaints Commission and HM Coroners in response to deaths in custody. Whilst the Begional on pala to a National Steering Group there has been much progress and it is intended to trial sed PER’s in _ the South Central Area in early 2015. The first is a “National” PER dopurient for use by court escorts and for inter prison transfers and a “Local” PER for use in hospital and Police escorts. A key development for the National document is the inclusion of the Suicide and Self Harm Alert form within the core document and for both the National and Local document the introduction of an eye catching “Red Flag” page to record and capture any risk/vulnerability information. This will provide all persons coming in to contact with the prisoner to record any concerns regarding the prisoner's welfare. Your second concern related to evidence that Mr Stoga had not been assessed for risk of self harm on return from his court appearances. PSO 3050 “Continuity of Healthcare for Prisoners” states that “ 6.2 Events that require a prisoner to leave the prison and pass back through prison reception can have a significant impact on the health of a prisoner. Exampies of such events are as follows: Court appearance Sentencing at court * Return from home visit 6.3 For those prisoners passing through reception, prisons must have protocols in place for screening them for any potential healthcare, or suicide/self-harm issues Evidence at the inquest confirmed that prisoners returning from court are seen by the Duty Reception Nurse to ascertain any change in circumstances, and assess whether there has been any impact on their risk of self-harm/suicide or to their mental health. In addition, staff can refer prisoners to healthcare at any time where they have concerns about a prisoner's mental health. Any returning prisoner subject to an ACCT, can be referred for a mental health assessment at any stage within the process. | hope that you find this information helpful. Yours sincerely,
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