Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0116, written 24 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Mar 2015 |
|---|---|
| Reference | 2015-0116 |
| Deceased | Stuart Baumber |
| Coroner | David Heming |
| Coroner area | Peterborough |
| Category | State Custody related deaths · Suicide (from 2015) |
| Organisation named | Cambridgeshire and Peterborough NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
In the matter of Stuart Megginson BAUMBER (Deceased)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
National Offender Management Service, Clive House, 70 Petty France, London SW1H 9EX
Sodexo Justice Services, One Southampton Row, London WC1B 5HA
1
CORONER
I am David Heming, Senior Coroner for the coroner area of Peterborough.
2
CORONER’S LEGAL POWERS
I 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 18/11/2013 I commenced an investigation into the death of Stuart Baumber.
The investigation concluded at the end of an inquest with a jury on the 30th January 2015.
The jury found the medical cause of death was :-
1a. Hanging
The determinations and conclusion of the jury was suicide where they found clear evidence of a
deliberate act by the deceased with intent to take his life by hanging at his cell at HMP
Peterborough between 22:30 on 14 November 2013 and 04:10 on 15 November 2013.
The jury also found for the purpose of this report the following :-
1. Between 29 October 2013 and 14 November 2013 there were one or more occasions when a
concern and keep safe form (the first step in the ACCT process) should have been opened.
2. A lack of understanding of and adequate training in the ACCT process, especially relating to
the requirement of when an ACCT book must be opened as stated in PSI 64/2011 contributed
to the ACCT process not being initiated.
4
CIRCUMSTANCES OF THE DEATH
The deceased encountered marital problems. On the 20th and 27th October 2013 he was subject
to detentions in a place of safety under s.136 Mental Health Act.
On the 28th October 2013, he poured petrol around his rented property and a fire was started. He
was extricated from the premises by fire brigade officers .
The deceased was a first time offender, charged with arson (reckless), and was remanded in
custody following a magistrate’s courts appearance.
At no stage was the deceased subject to the ACCT process despite the 136 detentions and the
nature of the offence and the fact he was a first time offender.
33 Thorpe Road, Peterborough, PE3 6AB
Tel 01733 452275 | Fax 0870 238 4085
The solicitor for the deceased telephoned the prison on one occasion to express concern about
him but no record could be produced of this or action taken.
A bail application at the Crown Court was unsuccessful on the 13th November 2013.
At approximately 04:10 on the 15th November 2013, an officer gained entry to his cell and on
opening the door the body of deceased fell to the floor. A laundry bag had been used as a part
ligature and there was also a shoelace ligature around his neck.
5
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. –
NOMS/SODEXO -
ANTI-LIGATURE STRIPS ON CELL DOORS
1. The deceased was a design engineer and his sketches found after death in his cell set
out diagrammatically how he deduced that the gap between the cell door and frame
would allow a ligature to be threaded through and that a wedge could be created with
paper pamphlets to prevent slippage of the ligature.
2. The risk of cell doors being used for ligature points is well known. In HMP Dovegate
alone some years ago, there were 3 suicides close in time where the upper hinge was
used as a ligature point.
3. However, whilst the current specification for cell door design now incorporates an anti-
ligature strip, there is no retrofit programme in operation and thus, there are significant
numbers of cell doors that do not meet the current standard.
4. The need to eradicate ligature points in cells has been the subject of recommendations in
PPO reports in Northern Ireland (JOHN MARTIN GERARD KENNEWAY published 10.12
2009 at recommendation 10 and COLIN MARTIN BELL published 9.1.2009 at
recommendation 9) and many Australian Coronial decisions and observations of
Coroners in England and Wales in the old Rule 43 and the new Regulation 28 reports.
5. Further, this was the subject of detailed commentary in the paper produced by the Jill
Dando Institute of Crime Science (University College London) where it was recognised as
being of paramount importance that there be removal of as many ligature points as
possible in cells and that remedial action would need to be taken as quickly as possible
before a new method spreads within and between establishments.
6. Evidence was given that the cost of a national retrofit programme for all doors being
adapted with an anti-ligature strip to meet the new design would be a significant
proportion of the current budget. However, given the particular vulnerability of prisoners
on induction and remand wings, a retrofit of those cells doors on such wings not meeting
the requirement would provide some protection and would be a measured response to
those prisoners who are known to be at heightened risk.
NOMS/SODEXO –
THE ACCT PROCESS
7. PSI 64/2011 and the Quick Time Learning Bulletin (issue 12 august 2012) which
clarified opening an ACCT was the subject of much scrutiny. There seems to be no
national pro forma document to guide staff through the process and document the
decision making. By contrast, the Act 2 Care risk assessment in the Scottish prison
system does provide a structured approach. A pro forma regime would have the
33 Thorpe Road, Peterborough, PE3 6AB
Tel 01733 452275 | Fax 0870 238 4085
advantage of providing an audit trail and can be reviewed for training purposes if
shortcomings emerge.
8. There appears to be on occasions an over reliance on assessment of current risk
as emphasised in the QTLB of 2012 by considering demeanour and presentation at the
reception stage. The PPO bulletin of March 2015 highlights deficiencies in this approach.
There are known risk factors for suicide and self-harm and active identification of relevant
risk factors from documentation and information (e.g. SASH forms and PERs and medical
records and an FME report) should be fully considered and balanced against apparent
mood so that the there is a comprehensive risk assessment.. A pro forma document
could record what factors and documentation have been considered and the reasons for
the decision.
9.
It is known that a prisoners risk of self-harm and/or suicide may increase in certain
circumstances. This applied to the deceased in this inquest. HMP Gartree have identified
measures to identify potential triggers and there has been developed a database on
trigger dates but only for those who are or have been subject to an ACCT. This could be
refined to deal with re assessment of risk for many prisoners if key factors exist. (See
Equality and Human Rights Commission paper in 2015 on Preventing Deaths in detention
of adults with Mental Health Conditions). Again, the PPO bulletin of March 2015
highlighted increased vulnerability where a restraining order was made and this could be
input into a database to prompt a review of risk. The deceased was served with papers
concerning harassment whilst on remand that may have emphasised that his marriage
was over and therefore increased vulnerability particularly when bail was subsequently
refused and victim impact statements were referred to in court.
10. The PPO report recommended that an ACCT should be opened whenever a prisoner has
recently self - harmed or expressed suicidal intent.
NOMS –
HEALTHCARE SCREENING.
11. The healthcare screening which is a question and answer discussion based on
specifically designed questions is prescriptive. It makes no mention of s.136 detentions
which would be a clear indicator of enhanced risk and the deceased had two such
detentions.
SODEXO -
ITEMS USED TO FACILITATE SUICIDE
12. Some prisoners at HMP Peterborough are allowed to carry their cell door key which is
placed on shoelaces tied together and placed around the neck of the prisoner which
clearly creates a self-made ligature for those who may be at risk.
13. In addition, the deceased referred to experimentation by suffocation in his diary by putting
a plastic bag over his head and some cells are known to have plastic removable bin liners
which can be used as a means to take life.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the power
to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
19 May 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.
8
COPIES and PUBLICATION
33 Thorpe Road, Peterborough, PE3 6AB
Tel 01733 452275 | Fax 0870 238 4085
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
(Bhatt Murphy)
(Bhatt Murphy)
Cambridgeshire and Peterborough NHS Foundation Trust (Kennedys)
Serco (DLA Piper)
I 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.
9
Dated 24th March 2015
Signature:
…………………………………………………………..
Mr David Heming, Senior Coroner for Peterborough
(signed electronically)
33 Thorpe Road, Peterborough, PE3 6AB
Tel 01733 452275 | Fax 0870 238 4085
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