Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0486, written 25 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Nov 2015 |
|---|---|
| Reference | 2015-0486 |
| Deceased | Dean Boland |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | State Custody related deaths |
| Organisation named | Birmingham Community Healthcare NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Director of Birmingham Prison 2. National Offender Management Service Birmingham 3. Andrew Selous MP, Prisons Minister 4. Birmingham Community Healthcare NHS Trust 1 CORONER I am Louise Hunt Senior Coroner for Birmingham and Solihull. 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 On 24/04/2015 I commenced an investigation into the death of Dean Ronald Edmund BOLAND. The investigation concluded at the end of the inquest 20th November 2015. The conclusion of the Jury at the inquest was: Dean Ronald Edmund Boland was discovered on the floor in Cell 12, 3rd Landing, B Wing in HMP Birmingham on 17th April 2015 at approximately 3:30 am by his cell mate. He was pronounced dead at 04:12 am. He died of mixed drug toxicity. Heading up to this he self‐administered various medication. A combination of prescribed and illicitly obtained medication were found to be present in the samples taken from him and subsequently found in his cell. Dean gained access to these non‐prescribed substance and legal highs by exploiting inadequacies within the prison. Searches that are carried out are inadequate. General awareness of drug use and the associated is lacking. Communication between departments concerned with maintaining the well being of drug dependent inmates is poorly implemented. Basic checks concerning the hoarding of medication are not being carried out. Medical regimes are not adequately monitored. Perimiters are poorly protected. This has resulted in a facilitation of a culture of irresponsible drug use within the prisons drug detoxification facility 4 CIRCUMSTANCES OF THE DEATH Dean Boland was returned to Birmingham prison for a breach of his licence condition on 29/01/15. He had only been released from the prison 2 weeks earlier. He had a known drug addiction. At 03.30 on 17/04/15 he was found unresponsive on the floor of his cell by his cell mate. Prison officers attended and paramedics were called. He was declared deceased in his cell at 04.12. Post mortem examination with toxicology confirmed the following drugs in his system at the time of his death: Drug name Normal use Level found Time frame Equivalent Whether in Dean for taking number of Prescribed drug tablets if by doctor applicable in prison Methadone Morphine 0.081 Last 2 days N/A No substitute milligrams per litre of blood (mg/l) EDDP – detected breakdown product of methadone Buprenorphine Drug addiction 0.001 mg/l Consistent Yes ‐ subatex therapy with therapeutic use Diazepam Drug 0.11 mg/l Consistent Yes withdrawal with symptoms therapeutic use Quetiapine Anti‐psychotic 0.41mg/l Used in the No drug hours leading up to death Pregabalin epilepsy, 1.8mg/l 1 tablet No anxiety disorder and neuropathic pain Gabapentin Epilepsy and 0.3mg/l Several 3 tablets No neuropathic hours before pain death Hyoscine – Treatment of detected No found in gastro buscopan intestinal disorders 5F‐AKB48 Legal high detected No synthetic cannabinoid The following are some of drugs found in his cell. The police confirmed that not all drugs found in the cell were tested. Type of drug Normal usage quantity Mirtrazapine 2 tablets and traces on silver foil Quetiapine Anti‐psychotic drug 1 tablet Gabapentin Epilepsy and 1 capsule neuropathic pain Pregabalin epilepsy, anxiety 2 capsules disorder and neuropathic pain Legal high 509mg package 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. There was a general lack of awareness and understanding of the drugs issues in the prison by prison officers. Two prison officers who worked on B wing said they were unaware of any problems with prisoners using illicit drugs including general medications. Prison officers need a comprehensive education program to understand what drugs are being used and sold and how prisoners come by those drugs. 2. There is a lack of multi‐disciplinary approach to drug issues within the prison. The evidence heard at the inquest confirmed that prison officers, health workers and DART workers do not adequately discuss trends and general drugs issues to ensure all staff are up to date and aware of the problems. It is accepted that patient’s confidentiality needs to be maintained but it is essential to discuss trends and significant events in a multi‐disciplinary way. 3. General medicine administration does not involve a check of the mouth so prisoners can easily conceal tablets to sell later. 4. Cell searches only take place for a certain number of cells each month on a random basis as prescribed by NOMS, or for targeted cells when there is sufficient intelligence. Intelligence searches only take place when there is at least 2 pieces of intelligence. Given the extent of the drug problem on B wing this seems insufficient. 5. Prisoners on B wing are not viewed or monitored at all overnight unless they are on an ACCT. This gives them a considerable period of time to smoke and use drugs knowing there will be no supervision or observation from prison officers. 6. The prison deploy a security officer to B wing at night (172 prisoners).This person is unable to interact with prisoners and is only there to answer call bells. This seems inadequate given that this group of prisoners are at high risk of drug use particularly at night when there are no cell checks. 7. DART workers are currently unable to access compact drug results as workers are unable to log onto the computer. 8. Prison officers are unaware of positive drug test results and therefore unable to take any action in response. 9. There are several exercise areas at the prison. Only two have netting. Further consideration needs to be given to netting other areas given the number of packages being thrown over the wall and then secreted by prisoners on their person. The inquest heard that only a small proportion of packages are seized as they come over the wall. 10. The prison should investigate whether 3 prison officer on duty in the exercise area is sufficient for 172 prisoners given the number of packages that are thrown over the walls every week. 11. At present there is no ability to search or screen prisoners or visitors for drugs concealed on their person when they come into prison. Given that this is a major source of drugs coming into the prison further consideration need to be given, on a national level, as to how concealed drugs can be identified for example with the use of a full body scanner. The current scanner can only identify metal objects. 12. Birmingham prison has 2 drugs dogs who work on a shift pattern. This means not every area in the prison can be covered as only one dog is on duty at any one time. Given that these dogs are the only current mechanism for identifying certain drugs consideration needs to be given to having more dogs so that prisoners and visitors coming into the prison will always be screened. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you G4S 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 21st 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 Chief Coroner and to the following Interested Persons the family and the PPO. 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 25/11/2015 _______________________ Louise Hunt Senior Coroner Birmingham & Solihull District
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.
. * inistr M n y of Equality, Rights and Decency Group J UST | C E National Offender Management Service - Ath Floor, 70 Petty France, National Offender London SW1H SEX Management Service t:0300:049 7051 Mrs Louise:‘Hunt Senior Coroner 50 Newton Street Birmingham B4 6NE 3 February 2016 Dear.Mirs Hunt, Thank you. for your. Regulation 28 report dated 25 November 2015 ‘addressed to. Michael Spurr, Chief Executive of the National Offender Management Service (NOMS), concerning the recent inquest.into the death. of Dean Boland at HMP. Birmingham ‘on 17 April 2015, Your report has been passed to the Equality, Rights and Decency (ERD) Group at NOMS headquarters, as we have responsibility for: the policy.on suicide prevention and self-harm.management and for sharing learning from. deaths in custody. | have consulted ‘with the Director: of ‘HMP* Birmingham. and ‘with Birmingham Community Healthcare NHS Trust :In formulating this response, which has been reviewed and approved by. each organisation (also ‘including Birmingham. and Solihult Mental Health Foundation Trust in view of ‘the shared healthcare Prangements, ‘at HMP Birmingham) prior to submission to you. The:report raises twelve concerns and | will address each one in turn. - Prison Officers needa comprehensive education program to understand what drugs are being used and sold and how prisoners come by those drugs Following the inquest, ‘training on supervising the administration, of opiate substitution medication has: been completed. with .detox unit staff and drug awareness training is scheduled for completion by 31 January. 2016. Drug strategy meetings are being held monthly and the. purpose ‘of these meetings. is to discuss. current issues:and trends around drug misuse within the.prison.and to agree actions and strategies going forward. These meetings-are attended by.a cross-functional group of interested. parties including clinical staff, residential managers and DART workers., From 9 December 2015. there has been. mandatory attendance at. these meetings. from. prison officers who work on B’ Wing. All staff on the. detox.and recovery unit will be required to sign a:document Indicating ‘that they have read the minutes of the meeting each month. Also included in this meeting is discussion-of those, prisoners receiving opiate substitution , medications who have. failed both mandatory and compliance based drugs tests. This provides officers with a heightened awareness of drug misuse on the residential units and allows them to factor that information into their observations and risk assessments. Prison officers, health workers and DART workers do not adequately discuss trends and general drugs issues to ensure all staff are up to date and aware of the problems B Wing is now managed outside of the normal residential function, by the drug strategy manager as part of his role. Each prisoner undergoing opiate substitution treatment has a named IDTS nurse and DART worker who work collaboratively with the individual on their recovery journey. Some members of the DART team are trained prison officers and others are drug and alcohol support workers from the prison’s partner organisation, Inclusion. Issues around the misuse of illicit drugs and prescribed medication are discussed. during monthly drug strategy and security meetings, During the meeting trends and issues around drug misuse of all kinds are discussed and actions to reduce the risk and likelihood of these occurrences are identified and put in place. Due consideration is given to confidentiality, but this does not prevent discussion around these issues. As a. result of these meetings significant amounts of work have been carried out with regard to emerging issues such as that of new psychoactive substances (NPS), which are widely misused both in custody ‘and in the community, This. work has been carried out collaboratively by clinicians, drug workers and prison officers. Following ‘intelligence around the illicit, use of Buscopan, «an. emergency medicines management meeting was convened on 20 April 2015, which included operational prison managers and well as clinical managers. ‘A joint decision was taken to suspend. use of Buscopan as a medication whilst awaiting further clarification. This was, also escalated through the NHS to ensure that other establishments were made aware of the potential for illicit use. eneral medicine administration does not involve a check of the mouth so oners ¢ gasily conceal tablets to sell later The administration of medication within the prison is carried out in fine with the. HMP Birmingham Medicines Code (an overarching medicines management policy) which reflects NHS Clinical Governance procedures. Administration of IDTS medication is supplemented by a check of the mouth’in fine with the compact signed by IDTS recipients to comply with their treatment pathway. This is similar to supervised consumption being requested by the prescriber in the community: Controlled drug administration is carried out by two nursing staff in line with medicine code policy. There is no clinical requirement to check the mouth of prisoners. However, in accordance with the published standard operating procedure, the designated practitioner observes the prisoner taking his medication and annotates the medication chart to indicate that it has been taken and swallowed. General medication is administered by one nurse in line with the standard operating procedure. This is observed and recorded in the same way. | An officeris present during the administration of both controlled and general medication to deal with any concerns of concealment or diversion raised by the nursing staff. The officer challenges unacceptable actions and uses the adjudication system and IEP scheme to deter and manage such behaviour. A review of a prisoner's prescribed medication may follow an incident of this nature. The number of. cell searches on B_wing seems insufficient given the extent of the drug problems . In line with contractual requirements agreed with NOMS, HMP Birmingham’s search cycle takes place over a6 month period. During that 6 month period each of the 996 cells within the prison is searched and each search is recorded on the appropriate form. All intelligence received is graded by intelligence analysts using the same systems as NOMS. This will rate the validity and reliability of the source and contribute to the decision about what action to take. The security team carries out target searches or intelligence-led searches on the basis of information received, but in addition to this ad hoc searching of. cells, prisoners and specific areas can take place at any time that it is deemed necessary. Cells are checked daily by officers as part of AFCs (accommodation fabric checks), and anything of concern can lead to the decision being taken to complete a cell search, There is an important balance to be struck between security and decency, ensuring that we maintain order and prevent illicit activities, but also that staff build positive, appropriate relationships with. prisoners'as part of dynamic security and to encourage responsible and respectful behaviour. Drug dogs are also deployed strategically for use in targeted areas, including B Wing. This. also assists in maintaining appropriate levels of security. Prisoners.on 8.Wing are not viewed or monitored overnight unless they are on an ACCT iving them a considerable period of time to smoke and use drugs Across the prison service there is no routine night time monitoring for prisoners other than those ‘subject to the Assessment, Care in Custody and Teamwork (ACCT) case management process and those who are segregated or located onan inpatient ward. It is important that during night state the reduced numbers: of staff are deployed to supervise those most vulnerable or at risk. Staff who are deployed’as night patrols can report suspicious activity to the person in charge during night state. This may lead to a drug test or a cell search being carried out. At Birmingham in 2015, 266 suspicion drug tests were carried out.on individuals as.a result.of staff submitting intelligence reports (IRs). stating that they believed illicit drugs were being used. IRs can be submitted by any member of staff at any time of day or night. The prison deploys a security officer to B Wing at night who is only there to answer call bells. This seems inadequate given that this group of prisoners are at high risk of drug use particularly at night when there are no cell checks The individuals deployed to B Wing are trained members of G4S staff. “In common with the practice in’all public.and private prisons, they are not fully qualified prison officers, but they have all.been specifically selected and trained for the role. Training includes modules on ACCT procedures, security awareness, health and safety and violence reduction. These are delivered during a two week training course that also makes provision for shadowing of existing security officers, including shadowing a night duty before becoming operational. On B Wing there is direct access for the security officer to senior staff located adjacent to the wing and to the medical team located on the 3 landing of the wing. The. clinical support during night state includes both a general nurse and a detox nurse, Any concerns can be discussed with the Night Orderly Officer, a manager grade who is present throughout the night. HMP Birmingham has no plans to introduce additional night staff, and they already deploy a-greater number than required by the contract with. NOMS. DART workers are unable to access compact based drug results as they are unable to log onto the computer This issue has been resolved since the inquest. At the time, only the dedicated DART staff carrying out the compact based drug tests (CBDT) had access to the database of results. Results were analysed and communicated to the DART team and information produced for the drug strategy meeting each month. Read only access has now been given to all members of the DART team to enable them to have contemporaneous information regarding the clients on their caseload. Prison officers are unaware of positive drug test results and.therefore unable to take any action.in response The details of individual prisoners testing positive on mandatory drug tests (MDTs) are communicated to ‘wing managers so that, in line with our zero tolerance ‘no drugs no violence’ policy, reduction to basic level on the incentive and earned privileges (IEP) scheme can take place. Wing managers brief staff about the information that they receive. A case note entry is added on PNOMIS whenever a prisoner tests positive. Personal officers review this information when making their weekly entries. A database is available on a shared drive of the local computer-system, accessible to all staff, with details of each prisoner who has failed a drug test, including information about what substance was taken, Only two exercise yards have netting, Further consideration needs to be given to netting rareas nu f_packages being thrown over the wall and then secreted by prisoners on their person. Only-a small proportion of packages are seized_as t! ome - fe) wall, Preventing illicit articles from entering the prison is a key part of the prison’s supply reduction strategy, and a vast amount of work has been undertaken, in conjunction with West Midlands Police, on closing down the most significant ingress point. Where the establishment considers it necessary it can submit bids for capital expenditure, and it would do so if it believed that additional security measures would make an impact on supply. The prison should investigate whether 3 prison officers on duty in the exercise area is sufficient for 172 prisoners given the number of packages that are thrown over the walls every week. : Staffing levels for exercise are risk assessed appropriately. B wing exercise yard has no external ingress point: the detox wing was moved to B wing on account of this, so that no throw overs can reach the exercise yard. Increasing the number of staff supervising exercise is not felt to be necessary, and it would not be the best use of resources. There is no availability to search or screen prisoners or visitors for drugs concealed on their person when they come into the prison. Further consideration need to be given, ona national level, as to how concealed drugs can be identified Prisons currently employ acomprehensive range of searching techniques and security measures to detect and uncover drugs at the point of entry or concealed in the establishment, and anyone caught with them will be punished and could face prosecution. Such measures include basic and enhanced rub down searching and full searching of prisoners, staff and visitors, as appropriate, and the use. of X-Ray machines, drug detection dogs and CCTV surveillance cameras and the imposition of closed (non-contact) visits. The forthcoming Psychoactive Substances Bill will control the sale and supply of all psychoactive substances, it includes .a new offence of possession of a psychoactive substance in a custodial institution, which will tackle the dangerous and pervasive use of new. psychoactive. substances in prisons, The Government recently commenced a clause’in the Serious Crime Act, which. introduces,a new. offence. of throwing any itern over. a-prison wall, including psychoactive. substances. Plans. are. in place to introduce widespread testing for psychoactive substances as part of the MDT process by April.2016, and NOMS has trained more than 300 specialist dogs to. search and detect new psychoactive substances in prisons. NOMS is. also-evaluating the effectiveness of body scanners to tackle. further the threat posed by drugs being smuggled into prisons, | Consideration needs to.be given to having more dogs so that prisoners and visitors coming into the prison.will always be screened HMP Birmingham has four operational. drug dogs. at its disposal, There are two dog handlers each.of whom has:two drug dogs: a passive drug dog (trained to search people) and an active drug dog (trained to search areas), The monthly security committee meeting discusses the deployment of and results from the drug dogs, with the aim of ensuring that the resource is used tactically in line with current intelligence and.known tisk factors. Ingress of.illicit substances into any establishment is not achieved through only one route, For example, prisoners subject to licence recall have been identified as a high risk group with regard to. potential trafficking, and dogs are therefore deployed when they are entering the establishment on return from court. Active dogs are also used as part of cell searches, and passive dogs can be used to support prisoner searches to deter'possession of items or locate them where they are suspected to be present. Two operations took place in 2015 where additional canine support was drawn from central resources to carry out ‘blitz’.operations on two residential wings. | hope'this provides you with assurance that the matters of concern that you have identified are being fully addressed. Yours sincerely
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