Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0269, written 30 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 | 30 Jun 2015 |
|---|---|
| Reference | 2015-0269 |
| Deceased | Blaise Farry |
| Coroner | Sean Cummings |
| Coroner area | West London |
| Category | State Custody related deaths |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: GOVERNOR, HMP WOORMWOOD SCRUBS 1 CORONER I am Dr Sean Cummings Assistant Coroner for the Coroner Area of West London 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 Inquest into the death of Blaise Francis Farry 4 CIRCUMSTANCES OF THE DEATH Mr Farry died as a result of hanging himself from a ligature made from a bed sheet suspended from the window at 1637 on the 19th January 2013. The Jury recorded a Conclusion of “Suicide – inadequate exchange of information between healthcare and prison staff in the weeks leading up to Mr Farry’s death” 5 CORONER’S CONCERNS Evidence was heard that indicated that staffing levels were insufficient to allow for a nominated Officer scheme to be instituted. The Prisons Ombudsman had made previous reports identifying the need for such a scheme but HMP Wormwood Scrubs had not instituted it. 6 ACTION SHOULD BE TAKEN To review the response of HMP Wormwood Scrubs to the recommendation in the Prisons Ombudsman’s report and where possible to institute a named officer scheme within the prison. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Person: (brother) 1 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 30th June 2015 2
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