Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0480, written 13 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 | 13 Dec 2016 |
|---|---|
| Reference | 2016-0480 |
| Deceased | Simon Turvey |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | State Custody related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
[2 | CORONER'S LEGAL POWERS °
i make this report uncer paragraph 7, Schedule 5, of the Coroners and Justice Act 2008 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013,
http /Avww legislation.gov uk/ukpga/2009/25/schedule/S/paragraph/7
| Iip/Awww legislation gov.uk/uksi/2013/1620/part/7/made
3 INVESTIGATION and INQUEST
| On 29/12/2015 | commenced an investigation into the death of Simon John Turvey, 27. The
: | investigation concluded at the end of the inquest on 24 November 2016. The Narrative
j _ Conclusion of the inquest Jury was Suicide Simon John Turvey was detained in HMP Woodhill.
: | He was found hanging in his locked cell at 05.45am on 29/12/2015. He was declared dead by
: paramedics at 06.12am,He deliberately suspended himself by the neck in his cell using a towel
: which caused his death. The relevant processes in place ai ihe time leading fo Simon's death, i
: Were followed by the staff and this did not highlight any requirement for enhanced monitoring due
: to suicide risk.On the 28th December 2015 there were no indicators that Simon was at risk of H
: suicide. The prison and healthcare authorities did not appear to be aware of a suicide risk for :
; Simon. But due to a failure of the Personal Officer scheme, and the family not pro-actively made —
| aware of how to share concerns, risk factors may have been missed. i
f EUAMCES GF THE DEATH ~ —— :
: The deceased was last seen alive when checked at 2046 28/12/15. Found hanging in cell at i
| 0544 29/12/15 by a towel ligature secured to top rail of bunk. 3 notes left in cell, Not on an :
| ACCT, no previous indications of suicidal ideation.
During the course of the inquest ithe evidence revealed matiers giving rise to concern: it became
| apparent that the family of Mr Turvey was not aware of the arrangements for the family to notify
| ihe prison if they had concerns as to his welfare. If they had known of the telephone fine to
report concerns they would have used it.
! in my opinion there is a risk that future deaths will occur unless action is taken. In the
. circumstances itis my statutory duty to report to you.
|
|
| The MATTERS OF CONCERN aro as follows. -
i Gangsrmes
i 1. That the details of the cause for concem line should be given to ail visitor and family
| members so that they can easily report their concerns to the prison. i
3)
I ACTION SHOULD BE TAKEN
‘in my opinion action should be teken te prevent fidure deaths and | believe you have the power
to take such action.
0? February 2046. |, the coroner, may extend the period.
| Your response must contain details of action taken or proposed io be taken, setiing out the
| timetable for action. Otherwise you must explain why no action is proposed.
You are under @ duty io respond io this repod within 58 days of the date of this repert, namely by |
COPIES and PUBLICATION
i y of my report ie the Chief Coroner and to the following Interested Persons
i the Governor of VWweodhill Prison. { have also sent it io to the Prison and
| Probation Ombudsman, and to NOMS who may find if useful or of interest.
iam 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 ihis report ta any person who he believes may find ft uselul or of interest,
: You may make representations to} é coroner, at the time of your response, about the
@ by the Chief Coroner.
| Torn Osborne
HM Senior Coroner for Mitten Keynes
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