Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0342, written 31 Oct 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 Oct 2017 |
|---|---|
| Reference | 2017-0342 |
| Deceased | Vilhelmas Borkertas |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | State Custody 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: Prevention of Future Deaths report
Vilhelmas BORKERTAS (died 21.11.16)
THIS REPORT IS BEING SENT TO:
1. Mr Kevin Reilly
Governor
HMP Pentonville
Caledonian Road
London N7 8TT
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 25 November 2016, one of my assistant coroners, Richard Brittain,
commenced an investigation into the death of Vilhelmas Borkertas, aged
24 years. The investigation concluded at the end of the inquest on 26
October 2017. The jury made a narrative determination, which I attach.
4
CIRCUMSTANCES OF THE DEATH
Mr Borkertas took his own life on 21 November 2016. His cellmate
described waking up in the evening needing to use the toilet, putting on
the light and finding Mr Borkertas hanging by a ligature from the window
bar.
The cellmate rang the cell bell.
1
It was answered by an operational support grade 21 minutes later. The
OSG then called for assistance and Mr Borkertas was cut down when
other members of staff arrived. They attempted resuscitation, but this
was unsuccessful.
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.
I gave a great deal of consideration at inquest to the exploration of the
time it took staff to attend to Mr Borkertas after his cellmate rang the cell
bell. However, I do not write about that now because I know that it is a
matter already under scrutiny by the prison, and I do not think there is
anything that I can helpfully add.
However, there is another matter that I should like to bring to your
attention.
Mr Borkertas described himself variously as heterosexual and bisexual.
The latter was recorded on his cell sharing risk assessment form. His
cellmate at the time of death described himself as being homophobic.
This was recorded on his cell sharing risk assessment form. However,
the two were placed together in a cell and I heard no evidence that
consideration was ever given to the potential dangers of this.
There is nothing to indicate that this had an impact upon the outcome,
but it might be devastating in another case.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 2 January 2018. I, the coroner, may extend the
period.
2
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 following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
HM Inspectorate of Prisons
National Offender Management Service
, Vilhelmas Borkertas’s father
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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
31.10.17
3
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.