Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0091, written 3 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Mar 2016 |
|---|---|
| Reference | 2016-0091 |
| Deceased | Stewart Akins |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Police 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.
SPECIMEN: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT |S BEING SENT TO:
1. Chief Constable, West Mercia Constabulary
CORONER >
lam DAVID DONALD WILLIAM REID, HM Assistant Coroner, for the coroner area of
Worcestershire,
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
INVESTIGATION and INQUEST
On 2 June 2015 | commenced an investigation into the death of STEWART AKINS, then
aged 51. The investigation concluded at the end of the inquest on 3 March 2016. The
conclusion of the inquest was a narrative conclusion.
The medical cause of death was 1a. Extensive head injury; 1b. Collision by train.
assaults. He was taken to Worcester Police Station, where his detention was authorised.
Throughout his time in custody it was recorded that Mr. Akins repeatedly stated his
intention to end his own life, and he was properly viewed as presenting a high risk of
suicide and/or self-harm. When he made his first appearance before the Worcester
Magistrates’ Court on 25.5.15, the Court was not told of this risk and no application was
made for him to be remanded in custody because of that risk and for his own protection.
Later that same day, having been released on conditional bail, he took his own life by
placing himself in the path of a train on a railway line near Malvern Walls."
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) Throughout Mr. Akins’ time in custody, entries were made on the custody record
which recorded his repeatedly stated intention to end his own life. Statements to
that effect were recorded as having been made, inter alia, to the Custody
t, ME to 2 nurse, to a Forensic Medical Examine:
En ou eee acartrenesctea igati at the
end of his police interview. The view was taken that he presented a high risk of
suicide/self-harm.
(2) The officer in charge of the investigation into the offences with which Mr. Akins
was eventually charged, a submitted an MG7 remand application
form for consideration by the Crown Prosecution Service, and with a view to bail
being opposed in the Magistrates’ Court. In that form, she set out objections on
CIRCUMSTANCES OF THE DEATH
The narrative conclusion stated:
"On 23.5.15 Stewart Akins was arrested on suspicion of having committed two domestic
@ number of grounds including a remand for Mr, Akins’ own protection,
However, in giving details substantiating that particular ground for opposing bail
she stated:
“AKINS has a problem with alcohol and mental health, clearly a combination
that does not mix well. AKINS spoke of his suffering with post traumatic stress
disorder (PTSD) and there is @ real concern that, being charged with offences
and now being NFA, he may pose a significant risk to not only those he
encounters, but also to himself. It is therefore requested that a remand in
sought for AKINS own protection, °
evidence at the inquest was that those details substantiating that
ground for opposing bail ( for Mr. Akins’ own protection ) were based solely on
her own dealings with Mr. Akins, and not on what was recorded in the Custody
Record. In fact, she was not aware of any of the entries recorded on the
Custody Record and was therefore not aware of the level of risk of suicide/self-
harm which those in charge of his detention felt that Mr. Akins presented, She
had not sought to check the Custody Record for any such entries, nor to speak
to the Custody Sergeant, nor had the Custody Sergeant sought to make her
aware of such entries.
Because was unaware of the contents of these entries in the Custody
Record, the description in the MG7 of the risk of suicide/self-harm which Mr.
Akins presented was significantly downplayed.
In addition to that under-reporting of risk, prior to the hearing in the Magistrates’
Court, EE was informed by the Senior Crown Prosecutor that she was
considering agreeing to bail with certain conditions. Those conditions did not
address the issue of risk of suicide/self-harm, bull accepted that she
had not sought to raise this with the prosecutor,
(6) A direct result of that under-reporting of risk of suicide/self-harm, and ofl
HE failure to raise it with the prosecutor, was that the prosecutor was minded
to agree to conditional bail as proposed. No objections to bail were raised with
the Magistrates, and conditional bail was duly granted.
{7) 1am therefore concerned that no chain of communication appeared to be in
place whereby [EE was made aware of the risks highlighted in the Custody
Record, so that an MG7 could be properly and fully prepared.
(8) The explanations for this appear to be either:
(i) that provision does not exist generally for such a chain of
communication to be in place; or
(ii) that provision does exist, and that lJ and/or the Custody
Sergeant(s) failed to operate in accordance with such provision
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe that 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 29 April 2016. |, 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:
RE Chicf Crown Prosecutor, CPS West Midlands.
WR brother of deceased )
| am also under a duty to send the Chief Coroner a copy of
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.
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.
GE West Mercia HBC-(s &} POLICE Ce) David Shaw Chief Constable West Mercia Police Headquarters, Hindlip Hall PO Box 55, Worcester WR3 8SP Email: chief@westmercia.pnn.police.uk Direct Dial: 01905 332233 Your Ref: DDWR/TW/W 1182.15 18" April 2016 Mr D DW Reid HM Assistant Coroner Worcestershire Coroner's Court The Civic Martins Way Stourport on Severn Worcestershire, DY13 8UN. Dear Mr Reid, Re: Stewart Akins deceased Regulation 28: Report to Prevent Future Deaths Further to my letter of 10” March 2016 please find below a response in relation to the issues raised within the Regulation 28 report: A full review into Mr Akins’ detention was conducted on the 4” June 2015. As you correctly identify, Mr Akins made a number of comments to persons he encountered within the custody environment highlighting his intention to harm himself upon his release. | am satisfied that these comments were properly and accurately recorded on the custody record and presented Mr Akins as an individual with a high risk of suicide / self harm. It is clear that there were failings in suitably communicating the degree of risk that was posed by Mr Akins following his movement from custody to the Magistrates Court. As a result of this incident West Mercia Police have immediately revised its’ practice to minimise risk and prevent future deaths by ensuring that all Prisoner Escort Forms (PER), whether completed by a detention officer or sergeant, are signed as accurate by the custody sergeant responsible for the detainees welfare prior to their release / movement from custody. The custody sergeant will have overall responsibility for ensuring that the risks are correctly documented and communicated. This practice will ensure that all known and documented risks contained within the custody record will travel with the person and properly inform others in their decision making processes. West Mercia has also ensured that mandatory training for custody sergeants includes the awareness of highlighting known risks and concerns to the OIC upon consideration of a MG7 remand application. This will enable prosecutors and the courts to make fully informed decisions about a person's vulnerabilities and needs. POLICE NON-EMERGENCY 101 Pe EMESOENCY ALWAYS CALL 999 www. westmercia police.uk v @wmerciapolice west mercia police | trust that these positive changes and enhanced channels of communication will deter incidents like this from occurring again. Yours sincerely, died ... David Shaw ‘ Chief Constable
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