Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0250, written 2 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jul 2015 |
|---|---|
| Reference | 2015-0250 |
| Deceased | David Hallett |
| Coroner | Andrew Barkley |
| Coroner area | Powys, Bridgend and Glamorgan Valleys |
| 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.
ANNEX A
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:
The National Offender Management Service (NOMS)
Governor HMP Rye Hill
Governor HMP Pare,
. The Chief Coroner
. The Family
CORONER
| am Andrew Roger Barkley, Senior Coroner, for the coroner area of Powys, Bridgend
and Glamorgan Valleys
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.
INVESTIGATION and INQUEST
On the 12" December 2014 | commenced an investigation into the death of David
James Hallet. The investigation concluded at the end of an inquest on 23% June 2015.
The conclusion of the inquest was that he died of “natural causes”
CIRCUMSTANCES OF THE DEATH
The deceased was serving a sentence of imprisonment and during a period when he
was transferred to HMP Rye Hill was admitted to hospital and was later diagnosed as
suffering from metastatic pancreatic cancer. He passed away on 4" December 2014 at
HMP Parc — having been transferred to their palliative care suite.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern.
{n 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:-
e The evidence revealed that in the early part of 2014, there was a nationally
designated re-roll for HMP Rye Hill which meant that it would be a designated
prison to receive convicted sex offenders.
Initial assessments undertaken during this process indicated that their
Healthcare department would be adequately resourced to be able to cope with a
influx of additional prisoners.
That was clearly not the case and the standard of care received by this prisoner
was found to be inadequate and certainly far below the standard that he might
have expected in the community.
The evidence indicated that one of the primary reasons for this was lack of
preparation by the Prison Authorities staff and an inability to cope with the types
of prisoners who were transferred to HMP Rye Hill. The clinical review
undertaken by Healthcare Inspectorate Wales was critical of the care that he
received at HMP Rye Hill and the evidence clearly indicated that a lack of
preparation for the re-roll and the lack of adequate resources were the primary
teason for this substandard care.
Whilst it is appreciated that HMP Rye Hill may not be subject to a further re-roll it
is of concern that other re-rolls nationally may be being considered and which
may conceivably give rise to issues similar to those presented in this case.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and 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 26" 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, The National Offender
Management Service (NOMS), Governor HMP Rye Hill, Governor HMP Parc
and (Widow) 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.
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