Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0200, written 26 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 | 26 May 2016 |
|---|---|
| Reference | 2016-0200 |
| Deceased | Ian Brown |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | State Custody related deaths · Suicide (from 2015) |
| Organisation named | Central and North West London NHS Foundation Trust |
| 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.
Thomas Ralph Osborne Senior Coroner for Milton Keynes REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Govenor, HMP Woodhill and to Mr. Andrew Selous MP Minister for Prisons CORONER | am Thomas Ralph Osborne, Senior Coroner for Milton Keynes 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Awww.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 20/07/2015 | commenced an investigation into the death of lan Keith Brown, 44 . The investigation concluded at the end of the inquest on 26 April 2016. The conclusion of the inquest was set out in the Jury’s narrative conclusion set out in their answers to the questionnaire. CIRCUMSTANCES OF THE DEATH Mr Brown suffered from mental illness and had been on remand at HMP Woodhill since the 10th January 2015 and occupied Cell 301 in House Block 3B.At 12:10 hours on Sunday the 19th July 2015 he was locked in his cell (he was the only occupant), he pressed his bell. PO Gary Lindop responded and Mr Brown said he wanted to speak to Senior Officer Miss Jones. He was told that she was on her lunch break and could probably come and see him after her break. At 13:10 hours 19/07/2015 PO Phil Arthur started his rounds to check the cells. Mr Brown's cell was the first one. The PO looked through the hatch and saw that Mr Brown was slumped forward in his chair facing the window. There was a belt ligature tied around his neck which was connected to the window. PO Arthur called a "code blue" (prisoner not breathing) through his radio for help. He then entered the cell and cut the ligature with his fish knife and proceeded to do CPR until Healthcare arrived. An ambulance was called and Paramedics confirmed death at 14:00 hours. A short note written to his sister was found in his cell. 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)During the course of the evidence | was referred to the most recent report from the HM Inspector of Prisons that highlighted “Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm, had not been implemented with sufficient rigour. (2) Deaths at the prison from suicide and self harm continue to rise. (3) The recommendation from the Inspectors is that there should be a “prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It should also include improvements in the quality of ACCT case management documentation, and the lessons learned from internal investigations into life-threatening incidents.” | have concerns that the recommendations will not be implemented and that past recommendations have been ignored. (4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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 22™ July 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Messrs Deighton Pierce Glynn Solicitors and to the Independent Monitoring Board, Prison Ombudsman. | have also sent it to HM Inspector of Prisons who may find it useful or of interest. | 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 m¢,.the@\coroner, at the time of your response, about the Signature_-_—(s WUV VV Ve Senior Coroner for Milton Keynes
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.
Equality, Rights and Decency Group National Offender Management Service 4th Floor, 70 Petty France, London SW1H 9EX t: 0300 049 7051 22 July 2016 Mr Thomas Osborne Senior Coroner The Coroner's Office Civic Offices 1 Saxon Gate East Central Milton Keynes MK9 3EJ Dear Mr Osborne Thank you for your Regulation 28 report dated 26 May 2016 addressed to Governor of HMP Woodhill, and , the former Prisons Minister, concerning the recent inquest into the death of Ian Brown on 27 February 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. I have consulted with the Governor of HMP Woodhill in formulating this response. You have raised concern in your report that you lack confidence that HMP Woodhill will implement recommendations from Her Majesty’s Inspectorate of Prisons (HMIP) and the Prisons and Probation Ombudsman (PPO), and address the matters of concern that you have raised in previous cases. Please be assured that the Governor absolutely understands your concern and is committed to making the improvements to be realised from implementation of these recommendations. Following the recent inspection by HMIP, a monthly forum, chaired by the Deputy Governor, has been introduced to monitor progress on the actions being taken in response to all recommendations relating to the recent deaths in custody. This forum will improve assurance of compliance. A whole establishment action plan, shared by the health provider and the prison, is in place and progress on this is formally monitored monthly and reported to both the prison Senior Management Team meeting and the newly established Clinical Governance meeting. As I explained in my letter of 6 February 2016 in response to a previous Regulation 28 report, the Deputy Director of Custody for High Security Prisons established a taskforce to conduct a review of safer custody processes at the prison, and this group now meets quarterly, chaired by the Deputy Director, to oversee the implementation of the action plan to address the recommendations of the review. Through the taskforce extra resources have been provided to the prison to assist in data analysis, focus groups and other research. At the same time the healthcare provider, Central North West London NHS Foundation Trust, completed a review of healthcare services at the prison. An early example of the improvement that is being driven by the taskforce is in the management of the ACCT process. The establishment has now delivered Case Management training to 90% of managers who chair ACCT case reviews. A new case review booking system is in place to improve the continuity of case manager attendance and to ensure that all members of the multi-disciplinary team are able to plan their attendance at review meetings. The prison is also implementing a system to provide each offender supported through the ACCT process with a designated case manager throughout the period for which the ACCT remains open. This approach will bring further improvement in the quality and consistency of case reviews and care plans. The planned improvements to safety at the prison go much wider than the ACCT process, including: an ‘every contact matters’ approach to the way that staff engage with prisoners; a streamlined early days in custody process, from the point of reception until the end of induction, managed by the residential team; and measures to increase the involvement of prisoners in decision-making, including the introduction of ‘citizenship’ groups to provide support to at-risk prisoners. I hope this provides you with assurance that the Governor of HMP Woodhill, and the Deputy Director of Custody for High Security Prisons, have put in place processes and governance that will achieve successful action in response to the recommendations from HMIP and the PPO, and the matters of concern raised in your Regulation 28 reports, and that this will bring the necessary improvements in safety at the prison. Yours sincerely
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