Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0461, 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 | 2016-0461 |
| Deceased | Calam Atour |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | State Custody related deaths |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 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.
DAVID RIDLEY
Senior Coroner for Wiltshire and Swindon
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Mr. Michael Spurr
Chief Executive
National Offender Management Service
Clive House
70 Petty France
London
SW1H 9EX
1
CORONER
I am DAVID RIDLEY, Senior Coroner for Wiltshire and Swindon
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.
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 the 14 May 2015 I commenced an investigation into the death of Calam ATOUR, aged 41.
Calam’s Inquest was opened on the 1 June 2015 and the final hearing lasted 2 weeks
commencing Monday 26 September 2016. As the circumstances of Calam’s death pointed to an
unnatural death I was required to sit with a Jury. The Jury concluded that Calam died as a result
of compression of the neck structures by a ligature and their conclusion and determination as
regards the mechanism of death was as follows:-
“Between 9.08am and 11.37am on the 13th May 2015 Calam Atour died in his room at Erlestoke
House by hanging himself by a ligature from the window.
Conclusion - Suicide. Narrative conclusion.
We have identified 5 circumstances which taken in combination made it probable that Calam
Atour's likelyhood of suicide was inadequately addressed.
1.
2.
After the removal of medication on the 22nd April 2015 there was no immediate follow-up
to personally explain the situation to Calam and this had an adverse effect on his state of
mind. The policy which requires individuals to make their own medical appointments
seems inappropriate if a medical intervention has itself caused the issue that makes an
appointment necessary.
The ACCT opened on Calam had a significant medical component and it would be
reasonable to expect that there should be sufficient medical personnel available to
support the review process. This was not forthcoming. Given Calam's preoccupation with
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
his medication it is possible that the lack of medical engagement in the process both
exacerbated this preoccupation and lessened its effectiveness.
In reference to the events of the 13th May 2015; the ACCT process appears to be
inadequate in identifying when immediate action may be necessary. It is possible that
had Calam’s threats to take his own life triggered a mandatory response, rather than
placing the decision making burden on the subjective opinion of individuals, that
increased monitoring might have carried him through to the next assessment that
afternoon.
There is a possibility that the lack of an assurance check at lunchtime on the 13th May
2015 contributed to Calam’s death.
There were staffing shortages and lack of coordination across the support networks for
Calam. It is probable that this situation exacerbated the circumstances listed above.”
3.
4.
5.
4
CIRCUMSTANCES OF THE DEATH
See Box 3 above.
5
CORONER’S CONCERNS
The MATTERS OF CONCERN are as follows:–
During the course of the Inquest I heard evidence from a number of Prison Officers who worked
at HMP Erlestoke who indicated that at the time of Calam’s death that there were staffing issues.
At least 3 had left HMP Erlestoke due to the working environment. One specifically referring to
stress amongst other factors, another mentioned that she left the prison service because the job
was no longer rewarding and I looked to explore my concerns in this area when I came to
the current Head of Safe Custody at Erlestoke. She accepted
question
that the situation was quite bad back in May 2015. Even taking into account “overtime payment
plus” following the benchmarking that had been undertaken a couple of years earlier, of the 88
that should have been in post the prison was operating with a staff shortfall of just over 15
members of staff. This represented an understaffing of just over 20%. In evidence, I heard that
other prisons did not have spare staff capacity, following the “benchmarking” process which was
undertaken to achieve efficiencies in the time of austerity. I have been told that there were and
are currently significant recruitment problems.
On the day of Calam’s death
for the large part of the morning was the only Officer
present on the Alfred Unit. As a consequence of her being busy she did not have a chance to
look at a recent entry in an ACCT document for Calam, which she said, had she seen the full
entry would have prompted her to speak further with Calam so as to ensure his welfare. It is
unclear as to whether or not the outcome would have been different had she done that.
In further questioning
I asked about the position today as many of the Officers I
spoke to who were still at Erlestoke said that the situation was now a lot better, which was
encouraging to hear. I was, however, alarmed to hear that actually the only reason it is better is
mainly due to the fact that 2 of the units were closed following an outbreak of violence during the
Summer of this year which resulted in considerable damage being caused to both Alfred and
Wessex Units by prisoners that has meant that they have had to be closed so that
refurbishment/repairs can be carried out. That is the main reason that there has been an
improvement and I was told that the scheduled re-opening of Alfred & Wessex was to be at
some point in 2017. Erlestoke is currently running with 13 vacancies unfilled which can be
accommodated on the basis of the closed units. I am concerned by this situation. I am aware
from
that potentially a fresh round of benchmarking is to be undertaken in the near
future as there are concerns nationally in relation to the number of prison deaths having risen in
recent years. In my opinion there is a risk that future deaths will occur unless action is taken. In
the circumstances my statutory duty is to report those concerns to you. The matter of concerns
are as follows:-
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
I.
II.
III.
I am concerned that unless the staffing number issue is resolved that when Alfred &
Wessex Units reopen next year it will again create a significant staffing issues and a
reduction of around 20% in operational personnel. I am concerned that this level of
reduction has the potential and propensity to create an unsafe system of work for the
prison officers (I heard during the course of the Inquest that 1 officer who was due to
attend Court to give evidence sadly was the victim of a serious assault whilst on duty at
Erlestoke recently). I am concerned that with a reduction in operational staff members
that there is a risk that such assaults will increase. Such assaults can result in serious
injury or even worse death. I am also concerned as regards the welfare of the prisoners
and as regards the ability of the prison officers as a result of the pressure on their
numbers to safeguard the lives of those in prison insofar as reasonable practicable
against the risk of prisoners harming themselves or others or even taking their own lives.
It was clear that there was a huge amount of reliance of goodwill amongst prison staff
but with the continuing pressure on staffing the reality I heard is that the goodwill gets
eroded overtime, as the ability to function in the workplace becomes increasingly
pressurised and more stressful. The position is not sustainable long term.
I fully appreciate that this issue overlaps with matters of Government policy in a time of
austerity but I have made this report out of a genuine concern for both the prison officers
and the prisoners at HMP Erlestoke and I am of the view that if I do not air these
concerns, that I would be discharging my statutory duty as a Senior Coroner having
heard the evidence.
Insofar as Erlestoke
It was also brought to my attention that in terms of benchmarking on the previous
occasion, that it did not take into account the type of prisoners that may be sent to a
particular prison.
its rehabilitation
categorisation and as regards the training and courses made available to prisoners that
a considerable number of the prisoners at Erlestoke are either “lifers” or on an
indeterminate prison sentence, both of these, of course, relate to serious crimes. I am
concerned that not taking into account the type of prisoner when determining
safe/efficient numbers of personnel could lead to a lower than safe number of personnel
available for duty. This concerns overlaps and dovetails with my concern at para I.
above.
is concerned, due
to
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the power
to take such action to address the concern highlighted above.
7
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 Senior 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Governor at HMP Erlestoke
Family of Calam Atour via their Lawyers, Tuckers Solicitors
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 Assistant Coroner, at the time of your response, about
the release or the publication of your response by the Chief Coroner.
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
9
Dated 12 October 2016
Signature_________________________
HM Senior Coroner for Wiltshire and Swindon
Copy to:
1.
2.
RadcliffeLeBrasseur
Solicitors representing Doctors at the Adcroft Surgery
Government Legal Dept.
3.
Avon and Wiltshire Mental Health Partnership NHS Trust
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
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