Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0454, written 23 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 | 23 Oct 2015 |
|---|---|
| Reference | 2015-0454 |
| Deceased | Samuel Gale |
| Coroner | John Sleightholme |
| Coroner area | South Yorkshire (East) |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
John Sleightholme Assistant Coroner for South Yorkshire (East District) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Kate Davies OBE Head Of Public Health, Armed Forces Health & Offender Health, NHS England, Birch House, Southwell Road West Rainworth Nottinghamshire NG21 0HJ 1 CORONER I am John Sleightholme, Assistant Coroner for South Yorkshire (East District) 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 27/05/2014 I commenced an investigation into the death of Samuel William Gale, 18 . The investigation concluded at the end of the inquest on 15 October 2015. The conclusion of the inquest was Open conclusion. The cause of death 1a Hanging 4 CIRCUMSTANCES OF THE DEATH Samuel Gale was received into custody at HMP Doncaster on 3rd May 2014. He was 18 years of age, a first time inmate who faced serious charges of rape. Furthermore, it was recognised by prior custody officers and healthcare nurses that he was very distressed at being barred from attending his father’s funeral by his mother and siblings who blamed him for his father’s suicide in February 2014. He had self-harmed and made an attempt at suicide recently and at times felt suicidal. He was immediately placed on an ACCT and half hourly observations were directed. On 16th May the ACCT was closed and he was found hanging the following day. 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. – triage by a mental health nurse. (1) Samuel was seen by a nurse on admission for a health screening followed by a the Nottinghamshire NHS Trust, who were responsible for healthcare at the prison, reviewed their note assessment procedures. Following Samuel’s death (2) The importance of an objective risk assessment has been recognised by the Trust which now uses a mandatory risk assessment from on System One. It is Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 320844 | Fax 01302 364833 understood that NHS England is in the process of procuring a new version of System One, and is invited to consider whether this procurement exercise provided an opportunity for formalising the risk assessment process throughout the prison estate nationally. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 320844 | Fax 01302 364833 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Ms Kate Davies OBE 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 14 December 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 HMP & YOI Doncaster, Mills and Reeve Solicitors, Lupton Fawcett Solicitors and Irwin Mitchell Solicitors. 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 23 October 2015 Signature_________________________ Assistant Coroner for South Yorkshire (East District) Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 320844 | Fax 01302 364833
John Sleightholme
Assistant Coroner for South Yorkshire (East District)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Deputy Director Hmp & YOI Doncaster Power Station Walk Marshgate
Doncaster DN5 8UX
1
CORONER
I am John Sleightholme, Assistant Coroner for South Yorkshire (East District)
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 27/05/2014 I commenced an investigation into the death of Samuel William Gale, 18 . The
investigation concluded at the end of the inquest on 15 October 2015. The conclusion of the
inquest was Open conclusion. The cause of death 1a Hanging
4
CIRCUMSTANCES OF THE DEATH
Samuel Gale was received into custody at HMP Doncaster on 3rd May
2014. He was 18 years of age, a first time inmate who faced serious
charges of rape. Furthermore, it was recognised by prior custody officers
and healthcare nurses that he was very distressed at being barred from
attending his father’s funeral by his mother and siblings who blamed him
for his father’s suicide in February 2014. He had self-harmed and made
an attempt at suicide recently and at times felt suicidal. He was
immediately placed on an ACCT and half hourly observations were
directed. On 16th May the ACCT was closed and he was found hanging
the following day.
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. –
i) The ACCT was closed by a person who had previous dealings with
Samuel without reference to healthcare, the chaplaincy or a unit
manager or any officer who had carried out an ACCT review.
ii) The Deputy Director was asked to consider whether only the person
who is primarily responsible for a prisoner’s ACCT should be the one to
close it.
Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS
Tel 01302 320844 | Fax 01302 364833
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
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
14 December 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
Notthinghamshire Healthcare Trust, Mills & Reeve Solicitors, Lupton Fawcett Solicitors
and Irwin Mitchell Solicitors.
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 23 October 2015
Signature_________________________
Assistant Coroner for South Yorkshire (East District)
Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS
Tel 01302 320844 | Fax 01302 364833
2 responses 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.
NHS England Our Ref:KD/KSM/Coroner Gale Your Ref: NJM/JS/rd/jp/457 15-2014 Birch House 10 November 2015 Ransom Wood Business Park Southwell Road West Mr JS Sleighthoime a Mansfield South Yorkshire (East District) 7 Coroners Court and Office Crown Court College Road Doncaster DN1 3HS Dear Ms Sleightholme RE: Samuel William Gale (Deceased) Further to your letter dated 27 October 2015 regarding the above named | have read the report and your concerns relate to the embedding of mandatory risk assessments in the national procurement of a new SystmOne. The new Health & Justice Information System will be a national system for the residential estate and as part of the deployment we are working with the Health and Social Care Information Centre and NHS England Clinical Reference Group to review a number of templates and first night screening and risk assessment is one of these templates. The timeline for the work is that from July 2016 NHS England will be undertaking the deployment and roll out to all sites of the new system, with an expectation that the full functionality will be in place by July 2017. This will include the roll out of any new national templates. | hope this clarifies your outstanding issues and please do not hesitate to contact me should you require any further clarification. Yours sincerely Kate Davies OBE Head of Public Health, Armed Forces and their Families and Health & Justice High quality care for all, now and for future generations
Bringing service to life OFFIC IAL Serco Home Affairs HMP & YOI Doncaster Marshgate Doncaster South Yorkshire ONS 8UX United Kingdom T +44 (0) 1302 760870 F +44 (0) 1902 760851 Our Ref: MB/REO www.gerco.com Your Ref: NJIM/JS/rs/jp/45715-2014 30 October 2015 Coroner’s Court and Office Crown Court College Road Doncaster DN1 3HS Dear Mr Sleightholme Re: Samuel William Gale Deceased DOB: 13.08.1995 — DOD: 17.05.2014 Further to your correspondence of 27 October 2015 and your report under Regulation 28. The concern raised relates to closure of the ACCT without reference to healthcare, chaplaincy or a unit manager or any officer who had carried out the review, and | have been asked to consider whether only the person who is primarily responsible for a prisoner’s ACCT should be the one to close it. | have considered the matter further and made reference to Prison Service Instructions on the management of the ACCT and conclude our actions are as follows: a) Policy changes have been made since this incident so that only a manager grade can close an ACCT. b) Case Managers will comprise of manager grades only. c) ACCT cannot be closed unless the case review comprises of at least two people and all the actions on the CAREMAP have been completed. d) It would be impractical to implement a process whereby only the person who is primarily responsible for a prisoner's ACCT should be the one to close it. Such action may leave a prisoner under a level of scrutiny and support that is not conducive to a prisoner's ongoing wellbeing. OFFICIAL Serco Home Affairs, a division of Serco Limited. A company registered In England and Wales No. 242246 Registered Office: Serco House 16 Bartisy Wood Business Park, Bartley Way, Hook, Hampshire, AG27 SUY United Kingdom OFFICIAL -2- Staff sickness, annual leave and lost days also render this impractical. Notwithstanding this, HMP & YOI Doncaster will seek to move to a case management model during 2016 whereby a nominated case manager manages a case load so that continuity of care is improved resulting in case reviews being completed by the same manager on a more frequent basis. The timing for completion of this objective is by June 2016. Yours sincerely Deputy Director HMP & YOI Doncaster OFFICIAL
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