Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0316, written 9 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Aug 2017 |
|---|---|
| Reference | 2017-0316 |
| Deceased | Sean Plumstead |
| Coroner | Grahame Short |
| Coroner area | Hampshire (Central) |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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.
Grahame Antony Short Senior Coroner for Central Hampshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HM Prison and Probation Service & Carillion (AMBS) Limited CORONER lam Grahame Antony Short, Senior Coroner for Central Hampshire 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:/Avww.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 19 September 2016 an investigation was opened into the death of Sean Patrick Plumstead aged 27. The investigation concluded at the end of the inquest on 18 October 2017 CIRCUMSTANCES OF THE DEATH Sean Plumstead was a convicted prisoner serving a 16 month prison sentence in HM Prison Winchester. He was due for release on 8 October 2016. He had no recorded history of mental illness, nor previous incidents of self harm. In the days leading to his death there were indications that he was distracted and thinking about suicide, but he did not disclose his plans and no ACCT had_been opened. On 15 September 2016 Mr Plumstead was sharin ith a fellow prisoner, Pa had that day moved into the cell with him. iii watchin: ist Mr Plumstead went into the toilet area, pulling the privacy curtain around rience? a sotvatec the emergency cell bell at 17.39 and at an unknown later time he found Mr Plumstead hanging by his neck from a ligature consisting of clothing material that was attached to one of the bars of the cell window. Members of the prison staff arrived and immediately called for assistance at 18:50 and they cut Mr Plumstead down prior to commencing CPR. He had no pulse initially but one returned and he was taken to Royal Hampshire County Hospital. A razor blade was found in the sink near the toilet and he presented with a laceration on the right side of his neck and a ligature wound along the front of the neck. His pulse and a heartbeat resumed but he had little brain activity. On 18 September 2016, medical staff took the decision to withdraw treatment and he died at 23:44 that day. His cause of death has been given as: 1a Hypoxic-ischaemic brain injury, bronchopneumonia and myocardial infarction ‘1b Prolonged cardiorespiratory arrest 1c Compression of the neck due to ligature suspension 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. — 1. ACCT Training | issued a Regulation 28 Report on 4 October 2016 in relation to a death of another prisoner at HMP Winchester HE «on cerning inter alia Assessment Care and Custody and Teamwork (ACCT) training plans and received a response from the Coroner's Ottice, Castle Hill, The Castle, Winchester, S023 8UL, Tel 01962-667884 | Fax 01962-667893 Ministry of Justice dated 12 December 2016 in which it was stated that refresher training was taking place for 48 members of staff that month and at least monthly thereafter and that 12 new prison officers were expected to complete the Prison Officer Entry Level Training course that includes training on suicide and self-harm awareness (SASH) and ACTT process before starting work at Winchester by March 2017. In an inquest starting on 13 March 2017 in relation to a death of another prisoner at HMP Winchester evidence was given by the prison governor that at August 2016 41% of staff had received ACTT training; at the date the evidence was given 61% of staff had received ACTT training; and that the aim was for 80% of staff to receive ACTT training by Autumn 2017. The Assistant Coroner issued a Regulation 28 Report on 11 April 2017 concerning inter alia ACCT training plans and received a response from the Ministry of Justice dated 21 June 2017 which stated that at the date of the letter 120 out of 162 prison officers at HMP Winchester (74%) had received ACCT training. Evidence adduced in the inquest into the death of Mr Plumstead disclosed statistics for the provision of SASH training had been completed as follows: e As at September 2016 77.29% of forward- facing prison service staff e As at September 2016 64.27% of all prison service staff e As at September 2017 72% of forward- facing prison service staff « As at September 2017 57% of prison service staff were “in date” with such training. The evidence was that the current aim is to achieve the 80% target by mid 2018. It was apparent from the evidence that due to staff turnover, a lack of trainers qualified and available to provide such training and other priorities, targets for SASH training are failing to be met and if anything the ratio of prison staff with the appropriate skills is reducing rather than increasing. This means that the risk of prisoners at risk of self harm and suicide may not be recognised by staff who have had no such training with whom they come into contact. Training of All Prisoner-facing Staff The investigation into the death of Sean Plumstead, including evidence heard during the inquest, has highlighted matters of concern relating to Carillion’s past and present operations at HMP Winchester and possibly at other establishments nationally. The evidence showed that in the 18 months before Mr Plumstead's death in September 2016, at least two Carillion staff were employed in prisoner-facing roles at the prison (in the Clothing Exchange Store) without any training in self-harm/suicide prevention (in apparent contradiction to the national policy - the Prison Service Instruction 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm/suicide prevention. It remains unclear whether the (Carillion) Works Manager and other Carillion supervisors (at a local and national level) are aware of the issue. The prison have since assumed the responsibility for the training of all staff in prisoner-facing roles but there is, as yet, no clarity on the obligations and assumptions which Ministry of Justice and Carillion were operating at the material time (2015-2016) nor indeed what arrangements will pertain in the future. Indeed, | have also heard evidence that the prison do not hold training records for Carillion staff. There is therefore some division of responsibility between the Coroner's Office, Castle Hill, The Castle, Winchester, $023 8UL Tel 01962-667884 | Fax 01962-667893 prison and Carillion and a risk that training of staff is missed because of the absence of such records. | consider there is a risk arising from my investigation that there was and continues to be a gap in training which Carillion is either unaware of or unconcerned with - a gap that may continue here and elsewhere. | understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but | cannot identify any requirement for self-harm/suicide management training, nor any commitment by Carillion to make staff available for such training by the prison as necessary. The apparent ambiguities in the arrangement could compromise the safety of prisoners that Carillion personnel are dealing with. | am also concerned of a risk in other prisons, where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. | invited Carillion to be an Interested Party to the inquest, a request which they declined to take up. Nevertheless, following the evidence in the inquest, the prima facie concerns have hardened. | consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of Justice both can address these concerns and clarify responsibilities. Emergency Cell Bells The emergency cell bell (ECB) in Mr Plumstead’s cell had been activated by his cellmate but the response to this took 10.5 minutes whereas the expected response time is 5 minutes. The evidence showed that there was and continues to be widespread misuse of ECB’s by prisoners particularly those on general wings, which leads to prison officers responding on occasions over an hour after the ECB has been activated. There are only limited sanctions available for enforcement of the proper use of the system by prisoners. The system allows no means of prioritising calls or identifying the time when the ECB has been pressed. Prisoners who have a genuine emergency have no alternative means of requesting assistance and therefore the risk is that there medical emergencies will not have a timely response and further deaths in such circumstances will occur. The current system is not fit for purpose and notices to prisoners are ineffective. Coroner's Office, Castle Hill, The Castle, Winchester, S023 8UL Tel 01962-667884 | Fax 01962-667893 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you HM Prison and Probation Service and (in relation to (2) only) Carillion (AMBS) Limited 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 14 December 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. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ° a and e Central & North West London NHS Trust | have also sent a copy of my report to the Governor of HM Prison Winchester who may find it of interest. | 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. 9 Dated 19 October 2017 Signature. nail Senior Coroner for Central Hampshire Coroner's Otfice, Castle Hill, ‘The Castle, Winchester, S023 8UL, Tel 01962-667884 | Fax 01962-667893
Grahame Antony Short Senior Coroner for Central Hampshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Governor, HM Prison Winchester CORONER | am Grahame Antony Short, Senior Coroner for Central Hampshire | 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. http://Awww legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 19 September 2016 | commenced an investigation into the death of Sean Patrick Plumstead, aged 27. The investigation is due to be concluded at the end of the inquest listed to commence on 09 October 2017. CIRCUMSTANCES OF THE DEATH The deceased Sean PLUMSTEAD was a prisoner in HMP Winchester serving a 16 month prison sentence. He was due for release in less than a month. On 15 September 2016 Mr Plumstead was in a shared cell. His fellow prisoner, was watching television whilst Mr Plumstead went into the toilet area, pulling the privacy curtain around himself. He later found Mr Plumstead hanging by his neck from _a ligature consisting of some material that was attached to one of the bars of the cell window fi caliec for prison staff who arrived and immediately called a 'Code Blue’ at 18:48 and cut Mr Plumstead down prior to commencing CPR. He had no pulse initially but one returned and he was taken to Royal Hampshire County Hospital Winchester where he was treated but then died on 18 September 2016. | ordered a forensic autopsy which was performed b on 20 September 2016 as a result of which he has reported the cause of death to be: 1a) Hypoxic-ischaemic brain injury, bronchopneumonia and myocardial infarction 1b) Prolonged cardiorespiratory arrest 1c) Compression of the neck due to ligature suspension. | have held Pre-inquest review hearings on 18 April 2017 and 11 July 2017 as a result of which | ordered inter alia disclosure by the Prison Service of recordings of telephone conversations involving Mr Plumstead and the recording of a post incident investigation by an assistant governor which | consider to be potentially relevant to the investigation. CORONER'S CONCERNS During the course of the investigation issues have arisen, 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. ~ (1) Winchester Prison has been unable to produce the telephone recordings and the transcripts provided are in summary form only and so may omit potential evidence. The systems in place for proper storage of such material appear to be inadequate or non-existent. Coroner's Office, Castle Hill, The Castle, Winchester, S023 8UL Tel 01962-667884 | Fax 01962-667893 (2) Winchester Prison has been unable to produce recordings of the interviews of staff and it has | been stated that due to resourcing constraints written transcripts of some of the interviews were not prepared. It is uncertain whether the relevant assistant governor will be able to give live evidence of the results of her investigation and one of the officers involved is on long term absence. The systems in place for proper storage of such electronic material appear to be inadequate and the administrative processes for transcription are insufficiently resourced. (3) This is not the first death in custody at Winchester Prison where potentially important documents or electronic material has been mislaid or not found because they have not been retained with specific prisoner records. There is therefore a risk that future deaths at the prison occur when such omissions are repeated. Coroner's Office, Castle Hill, The Castle, Winchester, S023 8UL Tel 01962-667884 | Fax 01962-667893 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you the Prison Governor have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report in a timely manner, namely by 01 September 2017 so as to avoid the need to further adjourn this inquest. |, 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 sent a copy of my report to the Chief Coroner and to the following Interested Persons aie: Central & North West London NHS Foundation Trust (CNWL). | have also sent it to Government Legal Department acting for the Ministry of Justice, Hodge Jones & Allen LLP acting (rR LeBrasseur acting for CNWL and the Prison & Probation Ombudsman who may find it useful or of interest. ! 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. Dated 09 August 2017 Signature. theo Senior Coroner for Central Hampshire Coroner's Office, Castle Hill, The Castle, Winchester, S023 8UL, Tel 01962-667884 | Fax 01962-667893
3 responses 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.
www.carillionplc.com Carillion plc 2nd Floor Lynton House 7-12 Tavistock Square London WC1H 9LT Mr Graham Short Senior Coroner for Central Hampshire Coroner’s Office Castle Hill The Castle Winchester SO28 8UL Dear Mr Short Sean Patrick Plumstead Deceased Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 report dated 19 October 2017 following the inquest touching the death of Mr Plumstead. We note the areas of concern you have highlighted and that there is a risk that future deaths may occur unless action is taken. I am now in a position to respond to you on behalf of Carillion and do so specifically in respect of the areas that touch Carillion’s work under its facilities management contracts with Her Majesty’s Prison and Probation Service (HMPPS). You raised the following areas of concern: 1. 2. ‘In the 18 months before Mr Plumstead’s death in September 2016 at least two Carillion staff were employed in prisoner facing roles at the prison (in CES) without any training in self- harm/suicide prevention (in apparent contradiction to the national policy – The PSI 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm suicide prevention’. ‘There is a risk arising that there was and continues to be a gap in training which Carillion is either unaware or unconcerned with – a gap that may continue here and elsewhere. I understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but I cannot identify any requirement for self- harm/suicide management training by the prison as necessary’. 3. ‘I have also heard evidence that the prison do not hold training records for Carillion staff’. 4. ‘I am also concerned of a risk in other prisons where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. I consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of justice both can address these concerns and clarify responsibilities’. PSI64/2011 I set out below the relevant extracts from PSI64/2011 Relevant sections within Safer Custody PSI 64/2011 state: Page 8 Specification Outputs -clause 27 ‘Contract/Service Level Agreements with third party providers reflect the need for multi-disciplinary working in relation to at risk prisoners. It is important that service providers are encouraged to contribute to the identification of risk procedures and multi-disciplinary case management reviews, either in person or in writing. Where appropriate contracts or SLAs must include this as a business requirement and key deliverable’. Page 10 Roles and responsibilities -paragraph 1 Making tomorrow a better place Registered in England and Wales no 3782379 Registered Office Carillion House 84 Salop Street Wolverhampton WV3 0SR CARILLION and the logo are trademarks of Carillion plc A Carillion Company www.carillionplc.com Carillion plc 2nd Floor Lynton House 7-12 Tavistock Square London WC1H 9LT ‘All staff in contact with prisoners must be trained to at least ACCT Foundation Level. ACCT refresher training must be provided according to local training needs’. CARILLION’S CONTRACTS WITH HMPPS I wish to clarify an apparent misunderstanding about our contractual obligations that you appear to be under following evidence that you heard during the inquest. By contract, Carillion provides a range of hard and soft facilities management services to HMPPS in public prisons throughout the country. However, having carefully reviewed our contracts with HMPPS, and contrary to the view that you formed during the inquest, there is in fact no contractual requirement upon Carillion and its staff to undergo SASH training, either as a business requirement, key deliverable or at all. Accordingly, prior to the inquest touching the death of Mr Plumstead, Carillion was unaware of the requirement for its staff to undergo SASH training. We are accordingly grateful for having had this issue drawn to our attention and immediately upon receipt of your Regulation 28 report set about investigating the matter and how we might work with HMPPS on it, the obligation to train all prisoner facing staff, being theirs. ACTION TAKEN/TO BE TAKEN 1. We have familiarised ourselves fully with PSI64/2011 and its updates so as to ensure compliance with HMPPS policies and procedures. 2. We have identified that SASH training is highly specialist and specific to a custodial setting and as such is not job specific in terms of the training we would ordinarily expect our staff to undertake within facilities management. Accordingly, it is not training that we are able to provide to our staff as employers. 3. Notwithstanding the contractual arrangements referred to above, we have made contact with colleagues at HMPPS and indicated our willingness and motivation to support Prison Governors to ensure that across our custodial contracts our staff are properly trained and supported in their work - in line with PSI 64/2011. 4. We have proposed to them that they provide us with a formal instruction under the contractual arrangements for our staff to undergo SASH training and confirm which categories of staff should undergo training. Our client has confirmed this week that it considers all Carillion prisoner facing staff should be required to undergo training. 5. We have proposed that as soon as we have that formal instruction to proceed on this basis, we issue a notice to all our site managers to make staff available to attend SASH training and we have suggested that HMPPS issues a notice in parallel to the People Hubs and Safer Custody Managers in each prison to provide SASH training to Carillion staff in line with PSI 64/21011. 6. We have also suggested that the People Hubs in each prison maintain a training record for all Carillion and agency staff within the facilities management contract and that there is an agreed mechanism whereby Carillion can receive management information on a monthly or quarterly basis on staff training planned and achieved across the contract. I trust you are assured of our intention to work with HMPPS on this issue and that our action plan is appropriate in the circumstances. Making tomorrow a better place Registered in England and Wales no 3782379 Registered Office Carillion House 84 Salop Street Wolverhampton WV3 0SR CARILLION and the logo are trademarks of Carillion plc A Carillion Company www.carillionplc.com Carillion plc 2nd Floor Lynton House 7-12 Tavistock Square London WC1H 9LT Yours sincerely Operations Director Central Government – MoJ Programme Making tomorrow a better place Registered in England and Wales no 3782379 Registered Office Carillion House 84 Salop Street Wolverhampton WV3 0SR CARILLION and the logo are trademarks of Carillion plc A Carillion Company
Michael Spurr
Chief Executive
HM Prison & Probation Service
8th Floor 102 Petty France
London
SW1H 9AJ
Email: ceohmpps@noms.gsi.gov.uk
G A Short
Senior Coroner
Coroner’s Office
Castle Hill
The Castle
Winchester
O23 8UL
09 January 2018
Dear Mr Short,
Inquest into the death of Sean Plumstead
Thank you for your Regulation 28 report of 19 October 2017 following the
conclusion of the inquest into the death of Sean Plumstead.
I know that you will share a copy of this response with Sean’s mother and I would
like first to express my condolences for her loss. Every death in custody is a
tragedy and the safety of those in our care is my absolute priority.
I am grateful to you for bringing these matters of concern to my attention, and I will
address them in the order in which they appear in your report.
ACCT Training
Your first concern is that targets for suicide and self-harm training at HMP
Winchester are not being met, and that as a result there is a growing proportion of
staff who have not been trained and may not recognise prisoners at risk of suicide
and self-harm.
I note that you have been given information about training in evidence at this and
other inquests, and in response to previous Regulation 28 reports. There have
recently been some changes in the training that is being delivered on this subject,
and I think it will be helpful for me to explain these changes before moving on to
address your point about targets.
PSI 64/2011 Safer Custody states that: “All staff in contact with prisoners must be
trained to at least ACCT Foundation level. From January 2012 ACCT Foundation
will be replaced by Introduction to Safer Custody and new staff must be trained in
this. ACCT refresher training must be provided according to local training needs.”
The Introduction to Safer Custody course to which this refers was replaced by the
Introduction to Suicide and Self-Harm Prevention course, known as SASH, in May
2017. Like its predecessor courses, the SASH course is being delivered to all new
prison officers as part of their entry level training, and to all new staff in other
prisoner-facing roles. It has also been developed in modular form so that it can be
delivered as refresher training to existing staff.
The ACCT training at Winchester about which you have previously been informed
was a two hour course, provided locally as refresher training, in accordance with
the PSI above. This has now been replaced by the SASH training, which consists
of six modules, including one on mental health awareness, totalling one and a half
days in duration.
The targets for the programme of refresher training have been revised to reflect
the fact that the new training takes much longer to complete. This, together with
the resourcing challenges that the Prison faced during the summer months, and
the lack of availability of trainers equipped to deliver the new course means that it
is now projected that the new course will have been delivered to all existing staff
who have contact with prisoners by the end of September 2018. Additional staff
will be trained as trainers in early 2018 in order to facilitate this.
Crucially, this does not mean that untrained staff who are unable to recognise
prisoners at risk are being deployed in the prison. The training targets relate to the
completion of the local refresher training. So, whilst the figures that you quote
show a temporary reduction in the proportion of staff who are “in date” in terms of
the local requirement to have undertaken such training within the last three years,
this does not mean that there are staff in prisoner-facing roles who have never
been trained. Moreover, the refresher training that the staff are now undertaking is
much more extensive, and contains more detailed information about risk, than the
ACCT training that was previously available. For this reason I am confident that
the changes that have been made to the training programme will have the effect of
improving staff awareness and capacity to identify and address risk.
You may also be interested to know that HMPPS has worked with Samaritans to
develop a Suicide Prevention Learning Tool that is now available on the HMPPS
intranet. This consists of a series of short films that communicate important
messages about suicide prevention through interviews with staff who share their
own experiences. They tackle some of the myths about suicide, explain how to
identify and help somebody at risk and describe the sources of support available
for staff who are affected by issues related to suicide and self-harm. Since the
films were released in October, feedback has been that staff find them engaging
and inspiring, as they recognise the important role that staff play, intervening every
day to support men and women at risk, whilst acknowledging that approaching a
prisoner who appears distressed can be difficult and providing useful tips about
how to do so.
Training of all prisoner-facing staff
Your next concern relates to the fact that prisoner-facing staff who were employed
by Carillion had not received any ACCT training and that the Prison did not hold
training records for these staff.
I can confirm that a number of Carillion staff in prisoner-facing roles at HMP
Winchester have been trained, and that records of training delivered to all staff,
including those who are not directly employed, are now held. These records do
not, however, include information about the internal training programmes of other
employers.
I accept that the requirement for prisoner-facing staff to undertake suicide and self-
harm prevention training was not specifically brought to the attention of Carillion
when their contract began, and I can confirm that a Service Manager’s Instruction
will be issued imminently to ensure that Carillion, and our other contractors, are
made aware of the requirement and their contractual obligation to comply with it.
Both HMPPS and Carillion are committed to ensuring that all relevant staff are
trained as soon as possible.
Emergency Cell Bells
Your final concern relates to the effectiveness or otherwise of emergency call bells
(ECBs), the expected response times and the widespread misuse of ECBs by
prisoners.
All staff at Winchester have been issued with individual notices about the
importance of answering ECBs promptly within the required time. Prisoners have
again been issued with information about the risks caused to themselves and
others by misuse of ECBs. In addition, the ECB response times are now checked
every day in order to improve accountability, and the Governor is preparing a bid
for funding to upgrade the ECB system. The range of sanctions available for
prisoners misusing ECBs will increase following the rollout of digital in-cell
equipment in 2018, as abuse of the ECB system may result in the removal of this
equipment.
At national level a learning bulletin for staff on the importance of responding
promptly to ECBs, and tackling abuse of them by prisoners, will be issued early in
2018.
Thank you again for bringing these matters of concern to my attention. Please be
assured that as well as driving the actions described above at Winchester,
learning from the circumstances of Mr Plumstead’s tragic death will be shared
widely across the prison estate.
Yours sincerely,
Michael Spurr
Safer Custody and Public
Protection Group
Her Majesty’s Prison and
Probation Service
4th Floor, Clive House,
70 Petty France,
London
SW1H 9HD
24 August 2017
Grahame Short
Senior Coroner for Central Hampshire
Coroner’s Office
Castle Hill
The Castle
Winchester
SO23 8UL
Dear Mr Short,
Pre – Inquest reviews into the death of Sean Plumstead
Thank you for your Regulation 28 Report addressed to The Governor, HMP Winchester, dated 9
August 2017, following the pre-inquest review hearings into the death of Sean Plumstead in
September 2016.
Your report has been passed to Safer Custody and Public Protection Group (SCPPG), which
has responsibility for the policy on suicide prevention and self-harm management and for
sharing learning from deaths in custody.
The Governor takes her responsibility towards preventing future deaths very seriously and
wishes to assure you that the concerns you raise have been addressed.
Her responses are laid out below.
1) HMP Winchester does have recordings of all telephone calls made by Mr Plumstead and will
provide you with a copy as directed. HMP Winchester have always had copies of the calls but
the system on which calls are accessed to be listened to is encrypted.
HMP Winchester does not have a dedicated typing resource. The prison have taken on a
temporary member of staff to access the encrypted PIN system, which has just the one point of
listening, to transcribe the calls. Once completed, copies will be made available to all interested
parties.
They will be catalogued and stored within a secure storage facility.
In addition HMP Winchester have implemented a new protocol for information and evidence
gathering from prison departments within specified timeframes. If these are not adhered to,
matters will be escalated to the Governor.
The Governor is clear that these processes should prevent HMP Winchester from being in a
similar position again.
2) The recordings of interviews with the two staff members have been located. The interview
discs had been left unsecured and the Governor’s secretary had secured them. Now the discs
have been sourced, they have been transcribed and the transcripts have been shared with
Government Legal Department and will be forwarded to yourself.
The Governor accepts that the discs should not have been left unsecured and apologises for
the delay in sending you the transcripts of them.
As a result of this, the Head of Business Assurance at the prison is carrying out a review of
accounting systems and storage of internal investigation material at HMP Winchester with a
view to identifying and rectifying areas of weakness.
3) A secure storage facility for documentation regarding any death in custody was not previously
available. This has now been ordered and it’s security handling will be written into the current
contingency plan for deaths in custody and managed by the Safer Custody team.
All material will be catalogued as evidence prior to its storage.
I hope that this response provides you with reassurance that HMP Winchester recognises the
concerns you have raised and has addressed them.
The Governor confirms that she is happy to answer any further questions that may arise either
from yourself, or from Mr Plumsteads’ family.
Yours sincerely
Safer Custody and Public Protection Group
Her Majesty’s Prison and Probation Service
See every Prevention of Future Deaths report matching State Custody related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.