Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0453, written 16 Dec 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2016 |
|---|---|
| Reference | 2016-0453 |
| Deceased | Mark Lilliott |
| Coroner | Julie Goulding |
| Coroner area | Liverpool and Wirral |
| Category | State Custody related deaths · Alcohol, drug and medication related deaths |
| 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 Governor HMP Liverpool
1
CORONER
I am Julie Goulding Assistant 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 5th January 2015 an investigation was commenced into the death of Mark LILLIOTT
, Aged 54. The investigation concluded at the end of the inquest on 15th December
2016. The conclusion of the inquest was Drug Related and the Cause of Death was
Ia Heroin Toxicity with Early Pneumonia
4
CIRCUMSTANCES OF THE DEATH
Mr Lilliot is a 54yr old gentleman who is an in-mate at HMP Liverpool. On the evening of
22nd December 2014, Mr Lilliot was returned to his cell and at 16.30 hours the cell door
was closed. At 18.45 hours the cell door was locked as per procedures. At 08.45 hours
the following morning, Prison officers unlocked the cell doors on the landing and
checked on the welfare of the inmates. On checking on Mr Lilliot they found him on his
bed, lying on his side facing the wall covered by a bed sheet. Due to his unresponsive
state, staff contacted the on duty Nurse. On arrival and with the help of the staff Mr Lilliot
was brought of the bed still on his mattress. The attending nurse found he was still
unresponsive with no pulse and that rigor mortis had set in. As a result CPR was not
attempted and Mr Lilliot's life was pronounced extinct at 09.12 hours.
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. –
When the two Prison Officers discovered Mr Lilliott they immediately tried to identify an
Officer with a radio to request immediate assistance from HOTEL1 (the urgent nursing
response within the prison) and subsequently determining that this was a CODE Blue
and therefore an emergency ambulance was also required. The two Prison Officers
therefore left the cell to seek the Senior Officer with the radio. It was reportedly noisy on
the wing at the time. The Prison Officers tried to shout down from level 5 to attract the
Senior Officer who they believed was on level 2 but this action was unsuccessful. One of
the Prison Officers therefore left the 5’s landing to go down to the lower levels and find
1
the Senior Officer, as he passed through level 4 he saw another Prison Officer who he
thought might have a radio but he didn’t and therefore he proceeded to lean over the
landing and shout again to try to attract the attention of the Senior Officer with a radio
and again it was reported that the Prison Officers shouts were not heard because of the
noise, it was a busy period with prisoners making their way to their daily activity. When
the Prison Officer shouted again to get the attention of the Senior Officer he was on this
occasion heard and the appropriate radio dispatches were immediately made in respect
of HOTEL1 and Code Blue. The delay, albeit relatively short, in accessing a Senior
Officer in possession of a radio on this occasion did not affect the outcome, Mr Lilliott
was already dead when he was discovered and had been for some time. However, it
might not have been the case that the prisoner was already deceased and it might have
been the case and it might be the case in the future that the fastest possible response
and action to radio for emergency help could make a difference to the outcome.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe 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. 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
(sister) and
MerseyCare NHS Foundation Trust
Liverpool Community health NHS Foundation Trust
(Partner)
I have also sent it to HM Inspectorate of Prisons, National offender Management
Service, the Independent Advisory Panel on Deaths in Custody, 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.
8
9
Julie Goulding
Assistant Coroner for the
City of Liverpool & Wirral
Dated:16 December 2016
2
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