Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0360, written 13 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 | 13 Oct 2016 |
|---|---|
| Reference | 2016-0360 |
| Deceased | Roy Hoey |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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:
The National Offender Management Service
Safer Custody
Equality, Rights and Decency Group
National Offender Management Service
4th Floor, 70 Petty France
London, SW1H 9EX
1
CORONER
I am André J A Rebello, Senior Coroner, for the area of Liverpool and Wirral
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 4th September 2014 I commenced an investigation into the death of Roy Patrick
HOEY, Aged 20. The investigation concluded at the end of the inquest on 4th October
2016. The conclusion of the inquest was
Ia Compression of the Neck
Ib Hanging
Roy Patrick Hoey committed suicide
4
CIRCUMSTANCES OF THE DEATH
The jury found after seven days of inquest hearing:-
Roy Patrick Hoey died at 05.22 hours on 04/09/14 at Altcourse, Brookfield Drive,
Fazackerley, Liverpool in Meeling Brown Wing, cell 14. He died by compression of the
neck from hanging by using a curtain as a ligature. We are sure that he put himself in
the position in which he was found with the intention of ending his life.
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. –
During the course of this investigation inquest a considerable amount of time
was taken up with the detailed questioning of witnesses around the meaning of
local and national safer custody guidance. The court was taken to Noms PSI
64/2011 and the apparent discrepancy between chapter 1 and chapter 5 was
highlighted.
1
Chapter 1 Page 10 -This related to the entire document “Management of
prisoners at risk of self harm to self, others and from others (Safer Custody)
All staff who receive information, including from concerned family members, or
observe changes in a prisoner’s behaviour which indicates a change in the risk
they pose to themselves, to others and/or from others must communicate their
concerns immediately to the Residential, Daily or Night Operational Manager,
and/or consider opening an ACCT Plan and make a record in an appropriate
source e.g. observation book, NOMIS, Security Information Report, ACCT Plan.
The court ruled that this general catch-all chapter covers everything covered
by the policy, self-harm, violence and bullying of others and protection from
others – so that is why there are alternative solutions.
Chapter 5 Page 26 - This chapter only related to the operation of the ACCT
Process – Assessment, Care in Custody and Teamwork
Any member of staff who receives information, including that from family
members or external agencies, or observes behaviour which may indicate a risk
of suicide/self-harm must open an ACCT by completing the Concern and Keep
Safe form.
HMP Altcourse – safer custody Document
“All prisoners suspected of being at risk of suicide or self-harm are placed onto
an ACCT Plan – All Mandatory actions in PSI 64/2011 must be followed.”
Admissions Policy at HMP Altcourse
“All prisoners will be assessed for risk of suicide or self-harm during reception
process. Upon arrival into admissions a prisoner’s documentation, PER or
other documents received from courts, such as suicide warning forms will be
checked for risks of suicide or self-harm Prisoners will be asked about this.”
And then
“Admission staff must raise an ACCT Plan when a prisoner is identified at risk
of suicide or self harm”
I ruled
1. I direct you that there is no internal conflict in PSI 64/2011 chapter 1 and
chapter 5 are referring to different things - And in any event the Altcourse
policy properly embraces national guidance in full.
The mandatory actions in the policy are italicised and I read again – “Any
member of staff who receives information, including that from family members
or external agencies, or observes behaviour which may indicate a risk of
suicide/self-harm must open an ACCT by completing the Concern and Keep Safe
form.”
2. This does not mean that every contact from family members or external
agencies or observed behaviour requires an ACCT to be opened. There needs to
2
be investigation, assessment and evaluation of the issue – which may indicate
a risk of suicide /self harm – and thereafter it is mandatory to open an ACCT.
3. The reason I make this ruling is not only that it common sense and the plain
English meaning of the paragraph - but also we have heard expert and
experienced evidence from a MOJ/ NOMs trained ACCT trainer that that is the
cascaded training down from NOMS – to each Prison and that is what is trained
to ACCT assessors and to all those who have basic ACCT training. So in each
scenario that has been raised was there assessment and evaluation of the
presenting issue which may indicate a risk of suicide and self-harm?
I am reporting this matter to NOMS as there was confusion for the witnesses
when different parts of the guidance were put to them and this may lead to
confusion as to what is required to apply the best practices of safer custody
within prisons. It may be that clarification of the updated policy will improve
safer custody, notwithstanding what the court was advised about the national
training. Clarification would have certainly reduced the length of time for the
inquest hearing considerably.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] 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 30th 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
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons HMP Altcourse and Mr Hoey’s Family.
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.
8
9
André Rebello
Senior Coroner for the
City of Liverpool
Dated: 13th October 2016
3
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.
Ministry of Safer Custody and Public Protection USTICE Nation National Offender Management Service 4th Floor, 70 Petty France, National Offender London SW1H 9EX Management Service t: 020 3193 6582 Mr A Rebello OBE Senior Coroner H M Coroner's Court Gerard Majella Courthouse Boundary Street Liverpool L5 2QD 17 January 2017 Dear Mr Rebello Thank you for your Regulation 28 report dated 13 October 2016 addressed to the National Offender Management Service concerning the i isi inquest into the death pf Roy Hoey on 4 September 2014 at HMP Altcourse. You have raised concerns about the confusion for the witnesses when different parts of the ACCT guidance were put to them and that this may lead to confusion as to}what is required to apply the best practices of safer custody within prisons. Chapter 1 details the circumstances in which you may open an ACCT such as if a member ff staff receives information or observes behaviour that indicates a change in risk. The policy states that the concerns should be reported and recorded in the appropriate documents. Chapter 5 states that the member of staff must open an ACCT if there are these concerns. NOMS acknowledges the potential for confusion regarding the opening of an ACCT, and this will be resolved in the revision of PSI 64/2011 due for completion by the endjof April 2017. It is not the intention of the policy to require staff to open an ACCT automatically in every circumstance where a risk may be indicated but it is expected that they communicate their concerns immediately to the Residential, Daily or Night Operational Manager, consider opening an ACCT plan and make a record of their decision in an appropriate source, for example the observation book and PNOMIS. | have passed on your concerns tothe policy lead responsible for the revigion of the policy, and they assure me that the revised version will be much easier for the |staff to read and understand. | hope that you find this information helpful. Yours sincerely
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