Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0274, written 13 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 | 13 Jul 2015 |
|---|---|
| Reference | 2015-0274 |
| Deceased | Douglas Birch |
| Coroner | Patricia Harding |
| Coroner area | Mid Kent and Medway |
| Category | State Custody 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Governor HMP Swaleside 1 | CORONER | am Patricia Harding, senior coroner, for the coroner area of Mid Kent and Medway 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 224 May 2013 | commenced an investigation into the death of Douglas Birch, 46. The investigation concluded at the end of the inquest on 9" July 2015. The conclusion of the inquest was that Douglas Birch died in his bed at HMP Swaleside between the hours of 19.10 on 14" May 2013 and 07.10 on 15" May 2013 of sudden arrhythmic death syndrome. He was found at 12.20 on 15" May 2013 by prison officers 4 | CIRCUMSTANCES OF THE DEATH Douglas Birch was a serving prisoner at HMP Swaleside in a single occupancy cell. On 15” May 2013 after a roll call at 7.10, the cells were unlocked at 08.15 for 30 minutes domestics before being locked again at 08.45. The cells were unlocked at approximately11.35 for lunch and locked again at approximately 12.10. His dead body was not discovered until 12.20 after a prison officer who had delivered mail to his cell without receiving a response raised concerns with a senior officer and the cell was entered. The state of his body was such that it could be established that he had been dead for a number of hours and likely before 08.00. No officer responsible for locking or unlocking his cell had sought to elicit a response from him, believing him to be asleep at the time. This was in contravention of PSI 75/2011 5 T 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) Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response from the prisoner upon unlocking a cell or were aware but did not act in accordance with the order especially where they assumed the prisoner was asleep (2) Prison officers were either not receiving Prison Service Orders and Instructions or if they did receive them, did not read them 6 | 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 9" September 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Hodge Jones Allen solicitors on behalf of the mother of the deceased, Imran Khan solicitors on behalf of the daughter of the deceased, Government Legal Department, DAC Beachcroft in respect of nurse, Gordons Partnership representing GP. | have also sent it to Prison & Probation Ombudsman 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. it DATE 13" July 2015 [SIGNED BY ee lta
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.
: PE ae Equality, Rights and Decency National Offender Group i National Offender Management Service Management Service 4th Floor, Clive House, 70 Petty France, London, SW1H 9HD Ms Patricia Harding Senior Coroner, Mid Kent & Medway Kent Register Office The Archbishop's Palace, Mill Street Maidstone Kent ME15 6YE 9 September 2015 Dear Ms Harding, RE: Regulation 28 report concerning the inquest into the death of Douglas Birch on 15 May 2013 at HMP Swaleside. Thank you for your report addressed to the Governor of HMP Swaleside, dated 13 July 2015, concerning the inquest into the death of Douglas Birch. Your report has been passed to Equality, Rights and Decency Group in the National Offender Management Service (NOMS) for a response, as we have responsibility for sharing learning from all deaths in prison custody in England and Wales. The two concerns you raise in your report are as follows: (i) Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response from the prisoner upon unlocking a cell or were aware but did not act in accordance with the order especially where they assumed the prisoner was asleep. (ii) Prison officers were either not receiving Prison Service Orders or Instructions or if they did receive them, did not read them. It is not reasonable to expect all prison staff to read all Prison Service Orders and Instructions. Rather, it is the responsibility of the Governor of each prison establishment to bring relevant instructions to the attention of staff and to ensure that they are reflected in local policies and procedures. In response to your concerns, the attached notice to staff was issued at HMP Swaleside on 10 August 2015. It sets out the local procedure for ensuring compliance with the mandatory requirement in PSI 75/2011 to which you refer, and requires staff and a supervising officer to sign to confirm that the welfare checks have taken place on each occasion. In order to ensure that the importance of welfare checks is better understood across the prison estate, NOMS is compiling a learning bulletin that will be published for the attention of all staff on our intranet by the end of September. | hope this provides assurance that your concerns have been addressed locally and that action has been taken to ensure that the requirement to undertake welfare checks is better understood in all prisons in England and Wales. Yours siacerely NOMS Equality, Rights and Decency Group
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