Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0394, written 29 Sep 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 Sep 2015 |
|---|---|
| Reference | 2015-0394 |
| Deceased | Lee Boden |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Thomas Ralph Osborne
Senior Coroner for Milton Keynes
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Director, National Probation Service
1
CORONER
I am Thomas Ralph Osborne, Senior Coroner for Milton Keynes
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 16/02/2015 I commenced an investigation into the death of Lee Anthony Boden . The
investigation concluded at the end of the inquest on 18 September 2015. The conclusion of the
inquest sitting with a jury was that the deceased had died as a result of Misadventure and the
lack of forward planning for his release from prison increased the risk of him using heroin.
4
CIRCUMSTANCES OF THE DEATH
Lee Boden had been released from HMP Lindholm on 13/02/15 and ordered to reside at an
approved premises in Great Holm, Milton Keynes.. He arrived at the Hostel at 2.20pm on
13/02/15. He was seen to leave the Hostel twice during the afternoon and returned at 7pm. At
7.15pm he entered the downstairs bathroom. At 11.10pm Hostel staff have attempted to enter
the bathroom but Mr Boden was slumped against the door. The Police were called and gained
entry. CPR was administered and an ambulance called. CPR was continued but without
success and Mr Boden was confirmed dead at 12.10am on 14/02/2015. Drugs and drug
paraphernalia were found in the bathroom with Mr Boden and needle marks were noted to his
groin. He had expressed that he did not wish to be in Milton Keynes as he wished to return
home to care for his mother.
After post-mortem examination, his cause of death was given as 1a) Central Respiratory
Depression 1b) Illicit Heroin Use
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) That the deceased was not informed of his intended placement in Milton Keynes until the day
before his release.
(2) The sudden arrival at the hostel would have increased his risk of using heroin.
(3) That he had been in the bathroom for almost four hours before he was discovered.
(4) Having just been released from prison and being unable to return to his home, he should
have been recognised as a vulnerable resident.
(5) There appears to be no protocol in place for continuing monitoring of new arrivals who remain
vulnerable.
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you, The National
Probation Service, have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
24th November 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
• The family of Mr Boden
• The Prison and Probation Ombudsman
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
Dated 29th September 2015
Signature_________________________
Tom Osborne
Senior Coroner for Milton Keynes
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
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.
National Offender Management Service Directorate of Probation Room 1.15 Clive House 70 Petty France London SW1H 9EX 12 November 2015: Mr Thomas Osborne Senior Coroner for Milton Keynes HM Coroner's Office 1 Saxon Gate East Central Milton Keynes MK9 3 EJ Dacor bw Osbrmne , LEE ANTHONY BODEN Thank you for your Regulation 28 report, dated 29 September, which was sent to Colin Allars, Director of Probation, following the inquest into the death of Mr Lee Anthony Boden. We are grateful for your comments and recommendations for improvement, which we have considered in detail. Your report identifies a series of issues, relating to communication, operational procedure and offender care, arising out of the evidence heard at the inquest. | explain below what action has been or is being taken in relation to each of the points you have raised. The deceased was not informed of his intended placement in Milton Keynes until the day before his release The decision to place Mr Boden in Approved Premises (AP) in Milton Keynes was taken at a late Stage, in response to information received on 9 February that indicated a potential risk of harm to a victim. This necessitated a change of accommodation plan, to ensure that a protection plan was in place. No places were available at Approved Premises in Cheshire at this point and the place at the Milton Keynes premises was not confirmed until the day before Mr Boden was due to be released. We nevertheless accept that a greater focus on planning for Mr Boden’s release, from an early stage, including better liaison with the Cheshire probation area, might have enabled him to be placed nearer to home. In addition, rather than relying on the prison to inform Mr Boden of the change of plan, It would have been preferable for his offender manager to make contact with him to explain the circumstances and to ensure he was aware what could be done to help him on his return to the community. Timeliness in developing release plans, and ensuring that service users are kept informed of changes, are learning points for the team and this will be addressed with managers and staff across the Buckinghamshire and Oxfordshire Local Delivery Unit. The sudden arrival at the hostel would have increased his risk of using heroin Drug use was discussed during Mr Boden’s induction on arrival at the AP. | enclose a copy of the local guidance on managing vulnerable residents, which highlights the risk of drug overdose for those newly released from custody. He had been in the bathroom for almost four hours before he was discovered Measures are in place to assure, as far as possible, the well-being of residents at the AP. The regime includes two “walk-around” checks during the day (the last at 5.30pm), as well as a curfew check of all residents at 11pm. Residents with earlier curfews are checked at their curfew time (as was the case with Mr Boden) and those subject to self-harm monitoring procedures are checked in accordance with a monitoring schedule set out in their self-harm management plan. Mr Boden had returned to the AP at 7pm for his curfew. He had a discussion with duty staff on his return and gave no sign of distress or other indication that his level of vulnerability had increased. The member of staff who spoke with him says that Mr Boden was pleased that he had succeeded in returning before his curfew and, while not happy about being at the AP, was positive about the prospect of discussing his situation with his offender manager the following Monday. The risk of overdose had been discussed with him at the induction interview. Both during his final weeks in custody, and again on release, Mr Boden had consistently stated that he was drug free and had no intention of using drugs. The Prisons & Parliamentary Ombudsman was satisfied that staff at the AP could not have anticipated Mr Boden’s actions. Having just been released from prison and being unable to return to his home, he should have been recognised as a vulnerable resident Mr Boden’s vulnerability was recognised, and his history of drug use was discussed with him at his induction meeting. Although there were no identified self-harm issues, it was decided to undertake overnight welfare checks. There appears to be no protocol in place for continuing monitoring of new arrivals who remain vulnerable The AP has a policy and procedures for assessing risk of self-harm and suicide and a system based on the Assessment, Care in Custody and Teamwork process (ACCT) for identifying those who require additional monitoring. In Mr Boden’s case, an ACCT assessment was undertaken and overnight welfare checks were established as a result. While both of the staff on duty were trained in first aid, neither had received specialist training in responding to a suspected drugs overdose. There is scope to explore additional training options, including the feasibility and desirability of staff administering heroin antagonists if residents are suspected of suffering from a drug overdose. | hope that the information provided above and the actions to be taken forward provide the assurance you are seeking of the National Probation Service’s commitment to addressing the issues you identified in your report. Yous :
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