Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0173, written 31 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 May 2017 |
|---|---|
| Reference | 2017-0173 |
| Deceased | Jonathan Palmer |
| Coroner | Kevin McLoughlin |
| Coroner area | London Inner (West) |
| Category | State Custody related deaths |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO
(1) The Rt Hon Amber Rudd |
The Secretary of State for the Home Department
Home Office
2 Marsham Street
London
SW1P 4DF
(2)
Governor of HMP Wandsworth
Heathfield Rd
London |
SW18 3HU
{ | CORONER
1am Kevin McLoughlin, an Assistant Coroner in the Inner West London Coronial Area.
2 | 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.
3 | INVESTIGATION
On 30 November 2015 an investigation was commenced into the death of Jonathan
David Palmer (‘Mr Palmer’). On 18 May 2017 | concluded the investigation at the end of
an 8 day Inquest, sitting with a jury. The Jury returned a Narrative conclusion.
4 | CIRCUMSTANCES OF THE DEATH
On 3 June 2015 Mr Palmer was brought to HMP Wandsworth on remand prior to a trial
which was listed to commence on 23 November 2015. On19 November 2015 at
approximately 1400 hours Mr Palmer's lifeless body was discovered suspended from a |
ligature in his cell. He was declared dead at 14.58 hours, after resuscitation efforts were
abandoned. The Inquest found the cause of death to be 1a Hanging.
In the period between June and November 2015 Mr Palmer had exhibited bizarre and
violent behaviour. The prison and medical staff attributed his behaviour to the effects of
an illicit drug, Spice. Mr Palmer's family (including his two brothers who were also held
on remand and shared a cell with him for part of the time) were convinced that he was
experiencing a developing psychotic illness in addition to his pre-existing psychiatric
conditions. The Narrative conclusion returned by the jury did not make a finding on the
balance of probability as to whether his behaviour prior to his death should be ascribed
to the misuse of illicit drugs, an emerging psychotic illness or a combination of the two.
Mr Palmer's community GP records were not obtained and hence those responsible for
his assessment and treatment in the prison from June 2015 onwards, had little
information available as regards his previous medical history. Relevant aspects would
have included his suicidal ideation in earlier years and the diagnosis of a major
depressive illness, approximately four months before he was remanded in prison.
Mr Palmer's family gave evidence that they endeavoured to make the prison aware of
their concerns about his mental health in numerous telephone calls to safer custody,
RAPt and the prison chaplains, as well as posting documents to the prison governor, but
the records available from chaplains and others did not enable the Inquest to determine
the date, nature and value of all of the information alleged to have been sent to the
prison.
Evidence taken at the Inquest indicated that Mr Palmer admitted at various times to
having smoked Spice. The Jury did not, however, find any causal link between any illicit
drug usage and the death.
One prisoner asserted in the course of his evidence that contraband material is
smuggled into the prison by corrupt individuals, but the investigation of this matter was
outside the scope of the Inquest.
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. —
4. There is no effective system by which the family of a prisoner can input
information they deem relevant to a prisoner's health needs and be assured this
will be disseminated to relevant teams within the prison, with appropriate
records being maintained in order to be able to demonstrate this has been done.
Families can be a source of valuable medical information, particularly, where GP
records have not been obtained and the individual himself may not be a reliable
source. It would be beneficial to have a clear, publicised conduit for a family to
provide relevant medical information to a specified department. The Inquest
was informed that a single point of contact has now been established, but it
remains unclear whether comprehensive records of all contacts will be
maintained, or whether this will result in the timely dissemination of information
to those with a role in the prisoner's welfare, such as healthcare staff, RAPt or
the chaplains. As the Personal Officer scheme appears to have been
abandoned at HMP Wandsworth there is no alternative individual for a
concerned family to approach.
2. The steps taken to control the inflow of contraband material into the prison
(such as the illicit drug known as Spice), appear ineffective.
Insidious substances such as Spice can mimic the symptoms of psychotic
illness and jeopardise life when unpredictable reactions occur to those using it.
Spice is also likely to adversely affect discipline within the prison, create the
potential for intra prisoner bullying (arising from drug debts) and stretch already
depleted healthcare resources. In order to combat this menace, steps should
be taken to identify the entry points in order that they can be more effectively
controlled and those involved, deterred.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe that the
Secretary of state for the Home Department and /or the Governor of HMP Wandsworth
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 19™ July 2017, 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 my report to the Chief Coroner and to the following Interested
Persons :
1. PF Bindmans LLP for the family of Mr Palmer (email)
2, WANSNEWEF Bevan Brittan for the South London & Maudsley NHS
Foundation Trust (email)
Legal Services for St George's NHS Foundation Trust (email)
PPO (email)
a Solicitors (email)
aplain, HMP Wandsworth, Heathfield Rd, London
SW18 3HU
Oahw
| 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.
31", May 2017
Kevin McLoughlin,
Assistant Coroner
Inner West London,
Westminster Coroner’s Court,
65, Horseferry Road,
London.
SwiP 2ED.
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.
Safer Custody and Public Protection Group Her Majesty’s Prison and HM Prison & Cor ta Probation Service 70 Petty France SW1H 9HD Kevin McLoughlin Assistant Coroner Inner West London Westminster Coroner’s Court 65 Horseferry Road London SW1P 2ED 6 July 2017 Dear Mr McLoughlin, Inquest into the death of Jonathan David Palmer Thank you for your Regulation 28 Report dated 31 May 2017, addressed to mma then Governor of HMP Wandsworth, at the conclusion of the inquest into the death of Jonathan David Palmer on 19 November 2015. Your report has been passed to the Safer Custody and Public Protection Group in Her Majesty’s Prison and Probation Service (HMPPS — the agency that has replaced NOMS), which is responsible for sharing learning from deaths in prison custody. HMPPS works hard to learn lessons from deaths in custody and in particular looks to recommendations from the investigations by the Prisons and Probation Ombudsman (PPO) and the findings of inquests to help us identify areas for improvement. | would like to thank you for drawing our attention to the matters of concern that you raised in your report and | will seek to address each in turn. Your first point is that there was no effective system by which the family of a prisoner can report their concerns about a prisoner's health needs and be assured that this information will be disseminated appropriately. In October 2016 the NOMS Safer Custody Group issued a Safer Custody Learning Bulletin titled ‘Receiving Emergency Calls: facilitating the sharing of risk information by families, Samaritans and others’ (Annex F). The bulletin is directed at all Safer Custody Teams, Custodial Managers, Reception/First Night Teams, Operations/Communication Room Teams and all staff whose duties may include receiving an emergency call from concerned families, the Samaritans or others. It states that ‘All prisons should have processes in place enabling anyone with concerns about a prisoner's risk (to themselves or others) at any time to make contact quickly with an identified member of staff equipped to ensure that appropriate action is taken.’ It goes on to say that it is essential that contact can be made with establishments 24 hours a day, seven days a week, and that calls are answered promptly. It states that families should be ‘provided with contact details which can be used in an emergency. At HMP Wandsworth, a Governor’s Order has been issued to all staff, stating that contact with prisoners’ families must be recorded on the National Offender Management Information system (NOMIS). This is to ensure dissemination of information to all departments including healthcare. You also expressed concern at what appeared to be ineffective steps taken to control the inflow of contraband material into the prison. HMP Wandsworth now has a robust multi-pronged approach in place to address this. Drug supply prevention is a continual-challenge for all prisons and particularly a large inner city prison such as HMP Wandsworth. New psychoactive substances (NPS) present another aspect to this issue which the prison-service was struggling with at the time of Mr Palmer's death. NPS remain a challenge as they can be easily disguised (e.g. sprayed on to writing paper) although dogs are now trained in their detection and the mandatory drug testing kits can now also detect NPS. In house training has promoted greater awareness and vigilance amongst staff but many of the supply routes remain the same. In order to disrupt entry routes of illegal items and contraband, HMP Wandsworth now conduct searches of all visitors prior to the visit and search prisoners after visits. There are varying methods of prisoner searches, including rub-downs, full strip searches or using the prison’s new body scanner. The BOSS chair (which identifies whether a prisoner has secreted items anally) and metal detection wands are also available tools in the search for contraband items. Mail and property sent to prisoners is searched and dogs are used wherever possible. An x-ray machine is used for property and the policy on property was updated in 2016, clarifying what prisoners are allowed to have in their cell, thus reducing available hiding places and means of trafficking. Drones are now a major threat to prison security with drone deliveries to Wandsworth extremely prevalent until September 2016, when a combination of police support, technological developments and more effective internal measures (intelligence gathering, disrupting particular prisoners, rapid response searches and fixing windows) led to a massive reduction. Since September 2016, there has been only one intelligence report relating to drones. HMP Wandsworth has seen significant success identifying corrupt staff and volunteers in the last year. Several staff have been permanently excluded with one significant find of contraband leading to an ongoing police investigation. Finally, in the next year the prison is due to change to a "smoke free" environment. This will be a massive challenge but once implemented will mean that any form of smoking is banned, making it much more conspicuous and easier for the prison to tackle NPS meaning more effective control and deterring those involved. | hope this response provides you with reassurance that HMPPS recognises the importance of the concerns you have raised. Thank you again for bringing these matters to our attention. Yours sincerely
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