Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0245, written 11 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jul 2016 |
|---|---|
| Reference | 2016-0245 |
| Deceased | Michael Williams |
| Coroner | Lydia Brown |
| Coroner area | Leicester City and South Leicestershire |
| Category | State Custody related deaths · Suicide (from 2015) |
| Organisation named | Leicestershire Partnership NHS Trust · University Hospitals of Leicester NHS 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr P. Novis. Governor, HMP Leicester 1 | CORONER 1am Lydia Brown, (assistant) Coroner, for the area of Leicester City and Leicestershire South 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 17 September 2015 | commenced an investigation into the death of Michael Williams. The inquest concluded on 7” July 2016. The jury made the following findings - The jury concluded the death was suicide. On 15th September 2015 between 21.45 and 22.45 Mr Williams died by hanging in his cell at 116 Welford Road. Although low traces of Mamba were found in his bloodstream, the influence of it on Mr Williams capacity to take his own life cannot be determined. At the time of his death Mr Williams was on 4 observations per hour. Mr Williams was last seen at 21.30 and was heard after this time. During these last two hours Mr Williams, on more than one occasion blocked the observation panel and inundation point of his cell door and wrote 2 suicide notes, 1 of which was ingested, and a note on the cell wall. Access to the cell was at 22.45 an inappropriate delay. The prison officers found Mr Williams hanging from the window bars by a ligature around his neck made from a torn bedsheet. Mr Williams was pronounced dead on 16th September 2015 at the Leicester Royal Infirmary. Cause of Death 1a Hanging 4 | CIRCUMSTANCES OF THE DEATH Mr Williams took his own life by use of a ligature, while in a single occupancy locked cell. At the time he was on an ACCT document, and had threatened to take his life earlier that day; had presented as tearful and anxious; had disengaged with prison officers; had covered his observation panel with both layers of paper and a bed sheet and the required 4 observations per hour had not been adhered to. 5 | CORONER’S CONCERNS Mr Williams should have been observed 4x every hour during the evening of 15” September 2015. Several of these checks were missed, and after he blocked the observation panel, he could only be heard, not seen. a) Observations (where they were carried out) were documented at precise 15 minute intervals, commencing on the hour, and were therefore predictable. This is not best practice and should be discouraged. b) There was no explanation for the missed observations. c) Mr Williams was unobserved for approximately 1 hour before the cell door was opened, and he was found deceased. The jury found this was an inappropriate delay and | agree with them. Clear guidance and training should be provided, and regularly repeated, to assist the Prison Officers in managing such situations in a timely way. 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 Monday 5" September 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons ER Parents) Chief Executive University Hospitals of Leicester NHS Trust. Chief Executive, Leicestershire Partnership NHS Trust. Thompsons Solicitors. Government Legal Department. Prison and Probation Ombudsman. | 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 ‘1c publi of your response by the Chief Coroner. [DATE] \) 41" July 2016 IGNED BY CORONER] is)
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.
~~.
~lational Offender
Management Service
Equality, Rights and Decency
Group
National Qffender Management Service
~1th Floor, Clive House,
7D Petty France,
London, SW1H 9HD
Lydia Brown
Assistant Coroner for Leicester City and Leicestershire South
23 August 2016
Dear Ms Brown,
Inquest into the death of Mr Michael Williams on 1S September 2015 at HMP Leicester
Thank you for your Regulation 28 Report of 11 ,luly 2016 addressed to the Governor of HMP Leicester,
concerning the recent inquest into the death of Mr Williams, Your' report has been passed to Equality,
Rights and Decency {ERD) Group in NOMS, as we are responsible for policy on suicide prevention and
for sharing learning from deaths in custody. This response has been prepared in consultation with the
Governor of HMP Leicester.
Yvu have raised three concerns, and i will address each in turn,
Mr Williams should have been observed 4x every hour during the evening of 15'" September 2015.
Several of these checks were missed, and after he blocked the observation panel, he could only
be heard, not seen.
(1) Observations (where they were carried out) were documented at precise 15 minute intervals,
commencing on the hour and therefore predictable. This is not best practice and should be
discouraged.
Prison Service Instruction 84/2011 Safer Custody sets out very clearly the requirement for observations to
be conducted at unpredictable times, far example four times an hour, as opposed to every 15 minutes.
Ali relevant staff at HMP Leicester have been reminded of this, and management checks are now in place
to ensure that staff are correctly undertaking observations, Ali ACCT documents are quality assured and
monitored by the Head of Safer Custody.
(2) There was no explanation for the missed observations,
In a notice to staff dated 24 March 2016, all staff were reminded of the importance of ACCT observations
The new Safer Custody toolkit that will be introduced in August 2016 provides clear instructions to staff
regarding ACCT procedures and the importance of conducting ACCT observations.
(3) Mr Williams was unobserved for approximately 1 hour before the cell door was opened and he
was found deceased. The jury found this was an inappropriate delay and i agree with them, Clear
guidance and training should be provided and regularly repeated to assist the prison Officers in
managing such situation in a timely way.
The contingency plan at NMP Leicester was revised in April 2016, and the amended plan has been
brought to the attention of staff through training and briefings. Staff have been made aware that they
must intervene quickly if the observation panel has been blocked and a prisoner is refusing to engage. In
particular, where there appears to be an immediate danger to life, cells can be opened by an individual
member of staff. In such circumstances, the staff member must make every effort to obtain a response
from the prisoner and then make a dynamic risk assessment of the situation based on what they can and
cannot see through the observation panel and on what they know of the prisoner. The toolkit mentioned
above will include guidance on haw to respond in an emergency and how to communicate with hard to
engage prisoners.
Thank you for bringing khese matters of concern to our attention. We hope that the contents of this letter
have been helpful in providing some national context, as well as assurance that they have been, or are
being, addressed locally at.HMP Leicester.
Yours sincerely
NOMS Equality, Rights and Decency Group
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