Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0142, written 17 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Apr 2015 |
|---|---|
| Reference | 2015-0142 |
| Deceased | Mark Groombridge |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Other 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 THIS REPORT IS BEING SENT TO: Director of Probation 70 Petty France LONDON SW1H 9EX = CORONER | am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South 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 3 January 2014 | commenced an investigation into the death of Mark Groombridge aged 52 years. The investigation concluded at the end of the inquest on 16 April 2015. The conclusion of the inquest was suicide whilst suffering severe depression. 4 | CIRCUMSTANCES OF THE DEATH Mr Groombridge had been in the community on licence from prison. On 12 December 2013 a warrant for his recall was issued. On 14 December he was arrested when he was an inpatient in a psychiatric unit and taken to HMP Dovegate. On 27 December he killed himself by jumping head first from a bed in the health [ care centre at the prison. 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. — (1) Before the recall paperwork was issued there was no direct conversation between the local offender manager and the clinician responsible for Mr Groombridge’s care in hospital. Should it not be policy for such a discussion to take place in any case where an offender is in hospital (be it for physical or mental reasons) before the recall is issued? (2) There was confusion about the recall process. The local offender rnanager believed that recall papers could be sent to the central NOMS unit in London and that they could be held there pending further direction. The evidence from London was that this would never happen and all recall requests are processed according to their urgency. Should all probation staff be reminded of what the correct process is? 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 12 June 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. 8 | COPIES and PUBLICATION “| | have sent_a copy of my report to the Chief Coroner and to the following Interested Persons: as widow of the deceased Harrison Bundey — solicitors for the family DLA Piper — solicitors for HMP Dovegate Treasury Solicitor — solicitors for the probation service Capsticks — solicitors for the mental health trust Independent Monitoring Board for HMP Dovegate | 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 17 April 2015 Aa A hk, Andrew A Haigh HM Senior Coroner Staffordshire (South)
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.
Equality, Rights and Decency National Offender Group . National Offender Management Service Management Service 4th Floor, Clive House, 70 Petty France, London, SW1H SHD Email: Mr Andrew Haigh Senior Coroner Staffordshire South 31July 2015 Dear Mr Haigh, Inquest into the death of Mr Mark Groombridge on 17 December 2013 whilst at HMP Dovegate Thank you for your letter of 17 April to FY Director of Probation, enclosing your Regulation 28 report following the inquest into the death of Mark Groombridge who died on 17 December 2013 whilst at HMP Dovegate. Unfortunately your letter was mislaid and | am sorry that you have not an earlier reply. Your letter has now been passed to Equality, Rights and Decency (ERD) Group, in the National Offender Management Service (NOMS), as we are responsible for the policy on suicide prevention and self-harm management and for sharing learning from deaths in custody. We are providing this response on behalf of the Directorate of Probation in NOMS. At the time of Mr Groombridge’s death the relevant guidance concerning the recall of offenders was Probation Instructions 07/2013 (Recall Review & Re-release of Recall Offenders) and 08/2013 (Determinate Sentenced Prisoners transferred under the Mental Health Act 1983). This guidance has been reviewed and the Director of Probation is of the view that the processes to be followed in that guidance were clear. The guidance states that offender managers are required to gather evidence and assemble the relevant facts to support a request for recall and that this will include liaising with anyone directly involved, including medical staff at a hospital at which an offender was a patient. As it is understood, the concern in relation to Mr Groombridge’s death was not that a decision to recall was taken in the absence of any necessary consultation, but that there was a failure to follow the correct process which led to Mr Groombridge being recalled despite the fact that a final decision to request a recall had not been made. The decision the offender manager took was a contingent one, in that should Mr Groombridge have removed himself from voluntary treatment then recall action would be taken. As Mr Groombridge did not so remove himself, no final decision to recall him was taken. The fact that he was nevertheless recalled resulted from a failure to follow the correct procedure set out in Probation Instruction 07/2013, which clearly states that recall papers are to be sent to the Recall Section in NOMS only after the offender manager has clear evidence that the offender has potentially breached the licence or has acted in a manner likely to cause serious harm. The guidance provides no provision to instigate recall before the anticipated event and, consistent with this, there are no arrangements for the Recall Section to hold recall papers pending a yet- to-be taken decision to recall. Probation Instruction 07/2013 has now been replaced by Probation Instruction 27/2014, with the same title, which became effective from 1 June 2014. It was updated on 1 February 2015. The Director of Probation is of view that the guidance given on the recall process remains clear, but is asking Deputy Directors to ensure that all probation staff are reminded of the procedures by 31 August. Public Protection Casework Section (PPCS), will be issuing a Senior Leaders Bulletin covering recall actions which will include a reminder of processes for all Probation staff to follow, PPCS will also be organising Recall Practitioner Forums in each National Probation Service (NPS) division at the end of the year. These forums will give staff and managers the opportunity to come together to discuss issues surrounding recall and review practice. | hope this provides assurance that the National Offender Management Service has clear procedures in place to ensure that the recall of prisoners takes place only following full consideration of relevant facts. Yours sincerely, NOMS Eauality, Rights and Decency Group
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