Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0366, written 12 Dec 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Dec 2017 |
|---|---|
| Reference | 2017-0366 |
| Deceased | Sidonio Teixeira |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| Category | State Custody related deaths |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE; This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO;
1, Governor — HMP Long Lartin
2.
CORONER
| am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire
CORONER'S LEGAL POWERS
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
On 20" June 2016 | commenced an investigation into the death of Sidonio Eugenio
TEIXEIRA then aged 59.
The investigation concluded at the end of the inquest on 7" December 2017
The conclusion of the inquest was narrative (attached), the medical cause of death
being multiple injuries
CIRCUMSTANCES OF THE DEATH
Mr Teixeira was murdered in the prison by another prisoner.
5 | Ci N:
my opinion there ts 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 ere as follows. —
efficacy of reporting, the appropriateness of analysis, the training of analysts and the
need for ongoing audit.
These issues and the adequacy of them were reflected in the narrative conclusion
reached by the jury.
In the course of the inquest a witness produced a previously unseen internal (and
critical) report regarding these issues which none of the witnesses had seen previously
(including the head of safer custody) notwithstanding that the report had been produced
over 12 months previously raising concerns that lessons might not have been shared
with appropriate staff,
{2)
{3)
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
ta cree re need
3 | INVESTIGATION and INQUEST
During the course of the inquest the evidence revealed matters giving rise to concer. In
(1); issues arose in the course of the inquest regarding the adequacy of intelligence, the
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you have
the power to take such action by conducting a general review of the intelligence
processes within the prison
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 6” February 2018 |, 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 senta of my report to the Chief Coroner and to the following Interested
Persons
| 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 2 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.
Signed '
Ma =
GU Williams 12th day of December 2017
H M Senior Coroner
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