Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0179, written 3 May 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 May 2016 |
|---|---|
| Reference | 2016-0179 |
| Deceased | Shalane Blackwood |
| Coroner | Stephanie Haskey |
| Coroner area | Nottinghamshire |
| Category | State Custody related deaths |
| Organisation named | Nottinghamshire Healthcare NHS Foundation Trust |
| 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: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The National Offender Management Service (NOMS)
2. The Governor, HMP Nottingham
3. Nottinghamshire Healthcare NHS Trust (as responsible for healthcare at HMP
Nottingham
4. NHS England, as commissioners of healthcare at HMP Nottingham.
1
CORONER
I am Miss Stephanie Haskey, Assistant Coroner, for the Coroner area of
Nottinghamshire
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
4
INVESTIGATION and INQUEST
Shalane Blackwood died at HMP Nottingham on 5th August 2015. An investigation was
begun, an Inquest opened and heard from 25th April 2015 to 3rd May 2015 before a Jury.
The Jury concluded that the duodenal ulcer should have been diagnosed and treated
and that systematic failures amounting to neglect by prison and healthcare staff
significantly contributed to his death.
CIRCUMSTANCES OF THE DEATH
Mr Blackwood died as a result of a bleed from a duodenal ulcer. His case was complex
and his presentation challenging due in part to his being unable to communicate
effectively. At the time of his death he was on a “four person unlock” in the Segregation
Unit and had been referred for specialist mental health opinion. There was evidence that
he had bled, for a reason unknown at the time, on 4th August but that no GP or hospital
referral was made following the blood being observed.
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 there is no proper provision for the care and supervision of prisoners who
present with complex physical and/or mental health needs. It is understood that
such a provision could be provided by means of an inpatient unit within the
prison, such as for example is the case at HMP Liverpool.
2. That at present, if a prisoner is assessed as needing a four person unlock, and
is within the Segregation Unit, there are insufficient prison staff to provide him
with a proper regime and to unlock him after lunchtime, for example to allow
1
3. That the use of New Psychoactive Substances (NPS) remains rife within the
prison, and presentations such as Mr Blackwood’s are not diminishing, and that
the Substance Misuse Team requires further staff to be effective in future.
4. That the documentary tool for decision making between prison staff and
healthcare staff, as to whether a prisoner is fit to remain in Segregation and
should do so, is unclear in design or in use.
5. That healthcare staff are insufficiently alert to the issue that physical symptoms
which require urgent medical attention may be occluded by mental health
issues.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisations, as appropriate to the issues above, 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………………... 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:
1. Mr Blackwood’s Family
I have also sent it to:
1. The Prison and Probation Ombudsman and the Care Quality Commission
who may find it useful or of interest.
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
[DATE] [SIGNED BY CORONER]
2
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