Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0447, written 26 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Oct 2015 |
|---|---|
| Reference | 2015-0447 |
| Deceased | Carl Foot |
| Coroner | Mary Hassell |
| Coroner area | Inner North 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: Prevention of Future Deaths report
Carl Robert FOOT (died 09.12.14)
THIS REPORT IS BEING SENT TO:
1.
Governor
HMP Pentonville
Caledonian Road
London N7 8TT
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 11 December 2014, I commenced an investigation into the death of
Carl Robert Foot, aged 33 years. The investigation concluded at the end
of the inquest on 23 October 2015.
The jury made a narrative determination, which I attach.
4
CIRCUMSTANCES OF THE DEATH
Mr Foot was found hanging in his cell at HMP Pentonville.
That morning, he had been told that he would be moving cells to a
different wing. This was simply to accommodate his methadone
prescription, but he did not want the move and was angry as a
consequence.
1
He then racially abused a prison officer and was put on a basic
regime. His television was taken away.
He later realised that he had not been taken to court that day as he
should have been.
The jury concluded that Mr Foot did not actually intend to take his life.
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.
Between 1.53pm and 2.51pm on the afternoon of his death, Mr Foot rang
his cell bell 13 times.
On occasion, including the last occasion, it was left up to 27 minutes
before being answered by a prison officer, rather than within the expected
five minutes. Mr Foot was found at 3.18pm by a passing prison officer.
He was resuscitated, but died four days later in hospital. If he had been
found earlier, he would have had a better chance of survival.
1. The jury found that there was an inadequate response by prison
officers to the cell bells, and that this was a contributory factor in
Carl Foot’s death.
2. Once a cell bell has been pressed, unless they remember hearing
it and the time of hearing it, officers on the landing have no way of
knowing when the bell was pressed, in other words, how long the
prisoner has been waiting. That makes it more difficult to prioritise
appropriately.
3. In terms of learning lessons for the future, which may include
learning by individual officers as well as on a systemic basis, there
was no exploration immediately after Carl Foot’s death of the cell
bell log and all those who heard/answered his bell that afternoon.
By the time of inquest, memories had faded.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation have the power to take such
action.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 2 January 2016. 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
HM Inspectorate of Prisons
National Offender Management Service
Probation and Prisons Ombudsman
mother of Carl Foot
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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
26.10.15
3
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