Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0007, written 11 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jan 2018 |
|---|---|
| Reference | 2018-0007 |
| Deceased | John Chapman |
| Coroner | Nicholas Rheinberg |
| Coroner area | Lancashire |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. 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. Governing Governor HMP Wymott (concerns 1 and 2)
2. Head of Healthcare HMP Wymott (concern 2)
1
CORONER
I am Nicholas Leslie Rheinberg, assistant coroner for the coroner area of Lancashire
2
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.
3
INVESTIGATION and INQUEST
In March 2014 an investigation was opened into the death of John Martin Chapman
aged 43. The investigation concluded at the end of the inquest on 10th January 2018.
The conclusion of the inquest was that the deceased died as a result of accidental
hanging.
4
CIRCUMSTANCES OF THE DEATH
On 23rd January 2014 the deceased was transferred to HMP Wymott. Within the Person
Escort Record and CNomis there were alerts in respect of two previous occasions when
the deceased had self-harmed or threatened self-harm and been placed on an ACCT.
This information was not passed on to the reception nurse and as a result the nurse did
not interrogate the deceased on these matters and give consideration, for instance, to a
referral to mental health or to taking such other action as may have been appropriate in
the light of the information and the deceased’s response thereto.
On 21st March 2014, the deceased, who up to that point had shown no signs of low
mood or distress, was found hanging in his cell.
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. –
1. TO THE GOVERNOR HMP WYMOTT
Although evidence was heard to the effect that currently at reception at HMP Wymott the
CNomis entries relating to a newly arrived prisoner are scrutinised by prison reception
staff to ascertain whether there are any self-harm or welfare alerts, it did not appear that
a direction exists to pass relevant information to the nurse carrying out the reception
medical screen.
2. TO THE GOVERNOR AND HEAD OF HEALTHCARE
There does not appear to be a mechanism at reception whereby information relevant to
the self-harm or well-being of a prisoner is routinely shared by prison staff with medical
staff carrying out a reception medical screen including alerts on the CNomis system. As
1
a result, there appears to be a danger that significant alerts concerning a prisoner might
not come to the attention of the reception nurse to enable the nurse to take appropriate
action and make relevant entries within the medical records.
Those in authority, giving evidence on behalf of the prison and healthcare on the subject
of reception practice, saw merit in there being a formal procedure agreed between
prison discipline staff on the one hand and healthcare staff on the other, for the sharing
of information relevant to a prisoner’s well-being, and for this to be accomplished
promptly.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and / or
your organisation 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 10th March 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the legal representatives of
the family and other properly interested persons.
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 coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9
Dated 11th January 2018 SIGNED
Assistant Coroner
2
2 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.
Michael Spurr
Chief Executive
HM Prison & Probation Service
8th Floor 102 Petty France
London
SW1H 9AJ
Email: ceohmpps@noms.gsi.gov.uk
Nicholas Rheinberg
Assistant Coroner
Preston and West Lancashire Coroners Court
2 Faraday Drive,
Fulwood,
Preston
PR2 9NB
09 January 2018
Dear Mr Rheinberg,
Thank you for your Regulation 28 Report of 29 November 2017 following the inquest
into the death of Christopher Talbot at HMP Preston on 28 November 2014. You
have addressed the report to the Governor and to Ministers, and I am responding
because the matters of concern that you have raised are all within my area of
responsibility. I am grateful to you for bringing them to my attention.
I know that you will share a copy of this response with Mr Talbot’s family and I would
like first to express my condolences for their loss. Every death in custody is a
tragedy, and the safety of those in our care is my absolute priority.
Reception officer training
You have drawn attention to the importance of ensuring that training for reception
officers includes their having access to PSI 07/2015 Early Days in Custody –
Reception, First Night in Custody, and Induction to Custody.
Every member of staff in reception at HMP Preston has been provided with a copy of
the PSI and set an objective to read and comply with it in their Staff Performance and
Development Record. Line managers will monitor the achievement of this objective.
Copies of the PSI are also available in the reception area.
You may also wish to be aware that we have introduced revised suicide and self-
harm prevention training for all staff in HMPPS, and that at Preston staff working in
reception are being given priority as this is rolled out.
Resuscitation aids
Your next concern is that not all staff at Preston carry resuscitation aids. Emergency
boxes containing resuscitation aids are currently available on all residential units at
the Prison, and there are plans for all staff with prisoner contact to be issued with
them by June this year.
Sharing learning from deaths in custody
Your third concern is that staff at HMP Preston are not notified about the manner of
each non-natural death that occurs. The establishment’s contingency plans have
been amended to instruct managers to provide relevant information to all staff in the
event of future deaths at the prison.
We are committed to sharing learning from the circumstances of deaths as widely as
possible across the estate; indeed, we frequently issue national learning bulletins to
raise staff awareness of risks identified from them.
National instructions on procedures at night
Finally, you suggest that an instruction issued at HMP Preston about procedures at
night could be issued nationally. We have reviewed the content of this local
instruction, and found that it has been drawn from existing national policies, including
PSI 64/2011 Safer Custody, PSI 24/2011 Management and Security of Nights and
PSI 63/2011 Management of the Local Security Strategy. As a result I am satisfied
that no further action is necessary, as the relevant instructions are already in place
across the estate.
Thank you again for bringing these matters of concern to my attention.
Yours sincerely
Michael Spurr
9/3/18
Bridgewater Community Healthcare
Head Of Healthcare
HMP Wymott
Ulnes Walton Lane,
Leyland, PR26 8LW
Dear Mr Rheinberg,
Telephone: 01772 442286
Email: K
Thank you for your Regulation 28 report dated 11th January 2018.
I note the concern expressed in your report that information relevant to an assessment of Mr
Chapman’s risk of self harm was not communicated by prison officers to the nurse carrying out
the reception health screen. Consequently, potentially important information was not known to the
reception nurse at the time that she assessed Mr Chapman.
The concern that you have addressed to healthcare is this: “There does not appear to be a
mechanism at reception whereby information relevant to self-harm…is routinely shared by prison
staff with medical staff carrying out a reception medical screen including alerts on the CNomis
system. As a result there appears to be a danger that significant alerts concerning a prisoner
might not come to the attention of the reception nurse”
It is, of course, recognised that it is important to share relevant information and the reception
nurse would expect prison officers always to communicate any significant information regarding
risk or welfare of which they were aware – whether this be contained in a PER document, on
CNomis, or otherwise. As you were made aware during the inquest, it was not the practice, at the
time, for the PER document to be passed by prison officers to the reception nurse and, as
regards CNomis, this is not a system managed by healthcare and nurses are not routinely
granted access to it.
As you note in your report, you were advised during the inquest that the prison and healthcare
intended to hold a meeting to discuss ways in which the sharing of information during the
reception process might be improved. I can advise you that this meeting took place recently on
March 1st.
As a result of the meeting between the prison and healthcare it has been agreed that henceforth
PER forms will be passed to the reception nurse as a matter of routine and the nurse must then
document within the SystemOne record that the form has been received and considered. It is
hoped that this “check” may be incorporated into the record system, as part of the existing
reception health screen template, and this possibility is currently being explored.
Thank you once again for bringing your concern to my attention.
Many Thanks
Head of Healthcare
HMP Wymott
Chief Executive: Colin Scales
Chairman: Harry Holden
Headquarters: Bevan House, 17 Beecham Court,
Smithy Brook Road, Wigan, WN3 6PR
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