Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0356, written 12 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Oct 2016 |
|---|---|
| Reference | 2016-0356 |
| Deceased | Wayne Cornlouer |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| Category | State Custody related deaths · Suicide (from 2015) |
| 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.
for The County of Dorset REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Governor, HMP Portland, 104 Grove Road, Portland, DT5 1DL CORONER | am Brendan Allen, Assistant Coroner for The County of Dorset 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://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST On 12" November 2014 | commenced an investigation into the death of Wayne Wesley Cornlouer. The investigation and inquest concluded on 237 September 2016. The conclusion of the Inquest was that Mr Cornlouer committed suicide. The jury also concluded that an ACCT should have been opened following an incident on 14" October, but that this did not more than minimally contribute to the death. CIRCUMSTANCES OF THE DEATH Wayne Cornlouer was found hanging in his cell on Collingwood Wing at approximately 5.50 am on 24" October 2014. The officer that discovered Mr Cornlouer called for “Immediate assistance on Collingwood”. The evidence suggests that his colleagues arrived at the scene within 5 minutes. It was only at this point that a call was put through to the control room to call for an ambulance. ol CORONER’S CONCERNS During the course of the inquest the evidence revealed maiters 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. — | understand that the coding system for a medical emergency, code red/code blue, was not part of the Night Orders at the time of Mr Cornlouer’s death. However, the Night Orders have since been amended to include this emergency coding. My concern is as to whether or not all staff are aware of the change in the Night Orders. The Coroner's Court, Town Hall, Bourne Avenue, Bournemouth, Dorset, BH2 6DY Tel 01202 310049 | Fax 01202 780423 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you The Governor HMP Portland of 104 Grove Road, Portland, Dorset, DT5 1DL 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 7 December 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 this report to Po Dorset Healthcare University Foundation Trust and the Ministry of Justice. | have also sent it to Her Majesty's Inspectorate of Prisons, the Prisons and Probation Service Ombudsman’s Office, National Offender Management Service and the Independent Advisory Panel on Deaths in Custody, 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 me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated : 12 October 2016 Signature HM Assistant Coroner for The County of Dorset The Coroner's Court, Town Hall, Bourne Avenue, Bournemouth, Dorset, BH2 6DY Tel 01202 310049 | Fax 01202 780423
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.
la PC M Tall st ry of Senior Caseworker: Safer Custody Casework T Safer Custody and Public Protection Group q National Offender Management Service National Offender Gere Management Service Cention SATTHIOEX Mr Brendan Allen HM Assistant Coroner for the County of Dorset BY EMAIL ONLY 15 December 2016 Dear Mr Allen Thank you for your Regulation 28 Report to Prevent a Future Deaths, addressed to the Governor, James Lucas, concerning the recent inquest into the death of Wayne Cornlouer at HMP Portland on 24 October 2014. Your Report has been passed to the casework team in the Safer Custody and Public Protection Group (SCPPG) in the National Offender Management Service (NOMS), as we have responsibility for the policy on suicide prevention and self-harm management and for sharing learning from deaths in custody. This letter is shared with you following consultation with colleagues at Portland, and ! am very grateful to you for allowing us a short extension to finalise this response. | note your concern that all staff at Portland need to be aware of the local Night Order which has been amended to include reference to the emergency codes and the requirement to call an ambulance promptly when staff use such a code. | can confirm that the relevant Notice to Staff was re-issued on 28 September 2016. This reminds all staff that an emergency code, either Red or Blue, must be called when there are serious concerns about the health of a prisoner, and that on receiving either emergency code the gate staff are required to request an ambulance. The Notice to Staff also confirms the nature of the injuries that should prompt the use of each of the emergency codes, and the further information that it is helpful to pass on to assist the local Ambulance Service. In addition, the local emergency code protocol has been distributed to all areas of the establishment and is displayed in prominent areas for easy reference, including the communications room. In addition to a copy of the emergency code protocol and the Notice to Staff, all existing staff will receive a personal briefing from their head of function. The induction programme for all new staff is being updated to include guidance on the local emergency protocol. Finally, the prison and the South Western Ambulance Service are intending to undertake a joint exercise in the near future to reassure both organisations that staff understand the local protocol and will follow required procedures in a real emergency. | hope this letter reassures you that the Governor of Portland has taken steps to ensure that all operational staff are familiar with the local emergency code protocol. Yours sincerely
See every Prevention of Future Deaths report matching State Custody related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.