Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0380, written 18 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 | 18 Dec 2017 |
|---|---|
| Reference | 2017-0380 |
| Deceased | Stephen Shaylor |
| Coroner | Elizabeth Earland |
| Coroner area | Exeter and Greater Devon |
| 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.
ANNEX A
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 JS BEING SENT TO:
1. The Rt Hon Amber Rudd MP
Home Secretary
Direct Communications Unit
2 Marsham Street
London SW1P 4DF
2. Dorset Health Care University
Trust Headquarters
Sentinel House
Nuffield Industrial Estate
Nuffield Road
Poole BH17 ORB
3. Care UK
Connaught House
850 The Crescent
Colchester Business Park
Colchester CO49QB
1 | CORONER
{ am Dr Elizabeth Ann Earland, Senior Coroner, for the coroner area of Exeter and
Greater Devon.
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 and INQUEST
On 8" January 2014 | commenced an investigation into the death of Stephen Mark
SHAYLOR, 42. The investigation concluded at the end of the inquest on 8" December
2017. The conclusion of the inquest was:
Cause of Death: 1a Hanging
The Deceased was arrested for drugs offences on 28" December 2013 and detained at
Exeter Custody Centre before attending and being sentenced at Exeter Magistrates
Court on 30 December 2013 before being sent to HMP Exeter on the evening of 30"
December 2013. He was seen by substance Misuse Team and placed on a drug
stabilisation regime, in a shared cell on main wing. He hanged himself and was found at
03:05 on 1% January 2014. He was not considered for S/H with a ACCT document, but
was subject to Healthcare night welfare checks. The check at 02:00 1/1/14 was not
done.
Whilst the Jury felt the (failure to) position the prisoner on a stabilisation landing was not
causative of the death, the inadequacy of the Healthcare night welfare checks may have
been a factor.
There was no system of continuous CCTV monitoring in the cells.
CIRCUMSTANCES OF THE DEATH
PMH - prev IVDU, moderate tricuspid regurg, ?renal function compromised
On evening of 30/12/13 was placed into cell A230 at HMP Exeter which was already
occupied by another inmate. He was seen by Healthcare and put on a stabilisation
regime by prison doctor for his drug habit. This involved a system of Night Welfare
Checks at 23:00, 02:00, 05:00. Very little conversation took place. 31/12/13 he spent
the day on the wing, cell was unlocked for most of the day, but not known if he left the
cell as his cell mate was out on the landings for much of the time. They did watch TV in
the cell together for 3-4hours. Approx. 1745hrs they ate together in the cell. Approx.
4800hrs cell locked for the night, they watched TV lying on their bunks but didn't talk, he
was on the top bunk. Late in the evening he got down and sat at table, cell mate turned
to face the wall and went to sleep. Cell mate woke in the early hours to find cell light off,
but TV still on and as he got up to turn off TV he could see him hanging from the window
bar. He was fully clothed with a ligature made from torn green cotton bedsheet wrapped
twice around neck. Prison staff alerted, healthcare cut him down and commenced CPR.
Paramedics attended and death recognised 0335hrs 1/1/14 but the Deceased had been
dead for some time. CID and SOCO attended. ‘Suicide’ note found in the cell.
An Investigation was opened on 9th January 2014.
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.
MATTERS OF CONCERN
(1) There were 38 places available on a corridor in C4 wing as a stabilisation wing
for dealing with inmates subject to Healthcare night welfare checks. Head of
Residence and Safety told the Court that the Prison received between 60 — 80
inmates per week needing detox and requiring placement in C4 cells which had
doors with larger windows for checking patients at night.
Professor Wall, substance misuse expert, said that the system for looking after
these inmates was not fit for purpose and that healthcare night welfare checks
(looking through a hatch in a cell door) were inadequate because it was not
possible to ascertain if a prisoner was breathing/alive by this method.
(2
S
(3) Night welfare checks and observations on an ACCT document are at best
intermittent and only continuous CCTV monitoring could spot a prisoner self-
harming.
S
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] 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 12" February 2018 I, 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:
The family of Mr Shaylor
| have also sent it of vio may find it useful or of interest.
lam 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.
[DATE] [SIGNED BY. RONER]
\s Qo\t
Je Alp = j >
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.
care & HMP Exeter 30 New North Road Exeter Devon EX4 4EX HM Senior Coroner Dr Elizabeth A Earland Exeter and Greater Devon Coroner's Office Room 226 Devon County Hall Topsham Road Exeter EX2 4QD 10 May 2018 Dear Madam Requlation 28: Prevention of Future Deaths report, Stephen Mark Shaylor | write further to your letter dated 29 March 2018 in order to address the additional points you have raised. Night welfare checks are carried out by Health Care Assistants (HCAs). At the start of the night shift, the nurse and HCA will print off the relevant welfare check list which will show all new additions made that day, as well as those prisoners who are already on the list. HCAs will then use that list and the printed template to assist them in conducting checks overnight. A copy of the template used was provided under cover of my first letter. You have raised 3 specific points and | address each in turn below:- 1. As above, the night welfare checks are carried out by HCAs. A nurse is also on duty overnight, but will not carry out the checks. However, they are based in the B2 health centre, which is in a central location in the prison, and are available should the HCA require assistance. The following day, the duty nurse from the Integrated Substance Misuse Service (“ISMS") will review the list of welfare checks conducted during the preceding night. As previously noted, the night welfare check does not replace the Assessment, Care in Custody & Teamwork (“ACCT”) documentation which is intended for the purpose of monitoring risk of self-harm or suicide. That responsibility lies with the prison staff. Care UK Health & Rehabilitation Services Limited - Registered in England No 10498997 Care &3 2. The acronym “MPCCC” stands for Multi Professional Complex Case Clinic. This weekly clinic is chaired by the Clinical lead GP or Clinical Lead Nurse and is attended by ISMS, a social care assessor (when needed), Mental Health and any other relevant contributors who are on site that day. If there was a need for a clinical observation of a prisoner overnight, then a care pian will be written, detailing the requirements. This will be reviewed daily and the prisoner will be referred for discussion at the MPCCC. 3. The ACCT process is a prison process and is operated and owned by HMPPS using prison documentation. To that extent, the overview and monitoring of the ACCT process does not sit with the healthcare team. However, any member of staff working at the prison can open an ACCT if they identify risks. Healthcare staff from the SMS, primary health or mental health team will attend ACCT reviews and record this on SystmOne. Therefore, these health care staff are responsible for contributing their knowledge regarding any risk factors which may include issues pertaining to substance misuse or detox. In my previous letter | had intended to underline that the use of the night welfare check has never been intended to replace ACCT documentation. This is simply because there are many prisoners suffering from substance withdrawal who would not require an ACCT; i.e. are not at risk of self-harm or suicide. Equally, there are many prisoners who may require an ACCT, but who have no issues requiring input from ISMS. | do hope the above clarification addresses the queries you raised. Yours faithfully Head of Healthcare HMP Exeter On behalf of Care UK Care UK Health & Rehabilitation Services Limited - Registered in England No 10498997
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.