Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0245, written 29 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jun 2015 |
|---|---|
| Reference | 2015-0245 |
| Deceased | Davin Short |
| Coroner | David Osborne |
| Coroner area | Norfolk |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: Head of Safer Custody & Equality HMP Wayland Griston Road Thetford Norfolk IP25 6RL 1 | CORONER lam DAVID OSBORNE Assistant Coroner, for the coroner area of NORFOLK 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 6 October 2011 an Inquest into the death of DAVIN PAUL SHORT aged 46 years was opened. The Inquest concluded at the end of the inquest on 25 June 2015. The conclusion of the inquest was that Davin Short died from natural causes with the medical cause of death being 1a Acute Lobar Pneurhonia. 4 | CIRCUMSTANCES OF THE DEATH Mr Short had been diagnosed and treated for a chest infection on 21 September 2011. Ata review appointment on 28 September 2011 it was considered that his infection had resolved. Expert evidence (ror I con freed that Mr Short received appropriate treatment and that his presentation on 28 September 2011 was of a resolved pneumonia. Mr Short rang his cell bell at 03:00 on 4 October 2011 and was spoken to by an officer when he complained of leg pain. He appeared to take advice arid get some rest. He was discovered unresponsive in his cell at about 08:15 hours on 4 October 2011, CPR was commenced but he was sadly pronounced deceased b' attending ambulance service at 08:43. In the opinion of the —« Mr Short was deceased when discovered. 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) During the course of the hearing | heard evidence that the prison did not have electronic system for recording cell bells and it was left to the discretion of individual officers whether to record a cell bell call in the Wing Record. | am therefore concerned that without guidance as to the making of a record of a cell bell call of medical nature an important matter may be overlooked with risk to life. (2) | also heard evidence that although there were now adequate radios for all three healthcare staff it was not made clear that if a single member of healthcare were on duty he or she must have a radio. | am therefore concerned that without a specific guidance, there is a risk that a single member of healthcare may not have a radio causing delay in responding to an emergency call and possible risk to life. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 24 August 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: BE (thr) | have also sent it to: HM Inspectorate Of Prisons National Offender Management Service Independent Advisory Panel in Deaths in Custody who may find it useful or of interest. | 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. 29 June 2015 x | se eeaeeenenens David Osborne Assistant Coroner — Norfolk Area
2 responses 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.
2. Ministryof rN Prt JUSTICE Lo HM PRISON National Offender “™™""""""""_ nvEsTOR IN PEOPLE SERVICE Management Service HM Prison Wayland Griston, Thetford Norfolk (P25 6RL Tel: 01953 804100 Fax: 01953 804220 www. hmoprisonservice.gov.uk Norfolk Coroners Office Your ref: 69-75 Thorpe Road . Norwich, Norfolk Our Ref: NR1 1UA Date:19/8/15 Response to Regulation 28 — Davin Short Death in Custody Dear Sir/Madam, My name is PY and | am the Head of Safer Prisons and Equalities at HMP Wayland. Within my role, | am responsible for undertaken actions as a result of a death in custody and am best placed to respond to the Regulation 28 letter regarding the death of Mr Davin Short at HMP Wayland. | also attended and gave evidence at the enquiry. In relation to the concerns raised regarding the recording of medical issues that may occur during the night | have ensured that the attached Governors Order was published to clarify this and have amended the Local Security Strategy to support this. In relation to the issue of radios to Healthcare staff, since the death of Mr Short, a ’ new radio system has been introduced with a greater number of radios. Alll Healthcare staff are issued radios upon arrival as a matter of course and as such, the circumstances discussed as part of the inquiry will not re-occur. Yours Faj Head of Safer Prisons and Equality HMP Wayland Making a Difference Together
ae : ; Equality, Rights and Dec National Offender 7 : Group ; . , : National Offender Management Service Management Service , . . Ath Floor, Clive House, - 70 Petty France, London, SW1H SHD . Mr David Osborne Assistant Coroner, Norwich 69-75 Thorpe Road Norwich Norfolk NRi 1UA - 44 September 2015 Dear Mr Osborne, Regulation 28 report concerning the inquest into the death of Davin Short on 4 October 2011 at HMIP Wayland Thank you for your report addressed to Matthew Spooner, Head of Safer Custedy and Equality at HMP Wayland, dated 29 June 2015, concerning the inquest into the death of Mr Davin Short. | understand that you have already received a tesponse from This was sent because he was not aware that it is our policy for the Equality, Rights and Decency Group to respond to all such reports addressed to the National Offender Management Service (NOMS), as we have responsibility for sharing learning from all deaths in prison custody in England and Wales. | would like to bring to your attention some information that was not included in his response, and | am grateful for the additional time that you have permitted me to do so. The two concerns that you raise in your repoft are as follows: (1) During the couse of the hearing | heard evidence that the prison did not have electronic system for, recording cell bells and it was lettto the discretion o individual officers whether io récofd-a cell bell call in the ‘Wing: Record. lam theres ae nmeerhed that wit iit guidance as to the:making of a record of a cell bell call of medical nature an - important matter may be overldoked with risk to life. (2) 1 also nee evidence, iat although there were now. w adeauate radios fof all thireé sen frit . a . x 4 responding to: an emergency call and possible tisk to life. As you know, each wing at HMP Wayland has a cell calf system, but, unlike in some prisons of more recent, construction, calls are not recorded electronically, and it is not- therefore possible to conduct an analysis of the number of calls or the time taken to answer them. There are currently no plans to introduce a system that permits electronic recording of calls, as this would be prohibitively expensive. In response to your first concern, the attached Governor's. Order was issued at HMP Wayland on 30 June 2015. It instructs staff to record medical issues that occur during the night in the wing observation book to ensure that they are brought to the attention of relevant staff the next day. The Local Security Strategy has been amended to reflect this procedure. In response to your second concern, as you were informed at the inquest, a new radio system with an additional number of radios has been introduced at HMP Waylarid since Mr Short's death. All healthcare staff are now routinely issued with radios upon arrival at the prison and this enables them to respond to emergency calls without delay. |. hope this provides assurance that your concerns have been addressed. Yours sincgyely NOMS Equality, Rights and Decency Group
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