Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0011, written 12 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 | 12 Jan 2018 |
|---|---|
| Reference | 2018-0011 |
| Deceased | Christopher Hutton |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Other 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Director of the National Probation Service CORONER ! am, Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 INVESTIGATION and INQUEST On 190/07/2017, | commenced an investigation into the death of Christopher Stewart HUTTON. The investigation concluded on the 8” January 2018 and the conciusion was one of Suicide. The medical cause of death was 1a) Hanging. CIRCUMSTANCES OF THE DEATH The deceased is a 48yr old single male who lives alone in a four bedroom detached property in an affluent area of Sale. In 2015 the Male was convicted for a number of offences, he is on the sex offender register and under supervision until 2021. On the 30th June 2017 his probation officer reported to Police that he had failed to attend a probation appointment with his supervisor on the 29/6. Officers attended the address but got no reply, they spoke to a neighbour who had a spare key and entered the house, they commenced a search and found him hanging and clearly dead in the upstairs back bedroom, he had put a butchers hook on the door and used what looked like a neck tie as a ligature his feet were a few inches from the ground, he was clothed and the indentations were consistent with the ligature used. 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) As part of his sentence, the deceased had been referred for an intensive Probation treatment programme. This formed a key part of the sentence. He was anxious to complete that part of the order. He had indicated that he would find it beneficial to complete the course. Despite the time that had passed since sentencing, he had not commenced the treatment plan. The reason given to the Court was that there was a high volume of demand and significant backlogs which meant that allocating places was very challenging. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9" March 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 sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Cousin of the deceased, 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. Alison Mutch OBE HM Senior Coroner 12/01/2018 nN
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.
ae HM Prison & Probation Service RECEIVED 09 FEB 2016 CK National Probation Service Business Strategy and Change Her Majesty's Prison and Probation Service fi 8" Floor Ms Alison Mutch OBE 102, Petty France HM Senior Coroner London Coroner's Court SW1H 9AJ 1 Mount Tabor Street Stockport SK1 3AG mailto: coroners. office@stoeckport.gov.uk Des Cormner \ Thank you for your Regulation 28 report, dated 12 January, which was sent to Colin Allars, Director of Probation, following the inquest into the death of Christopher Stewart Hutton. Mr Allars has now moved to a new post. His replacement as Director of Probation is Ms Sonia Crozier, who has asked me to reply. We are grateful for your comments and recommendation for improvement. You are concerned that the sex offender treatment programme that Christopher Hutton was to undertake had not yet commenced at the time of his death. You will be aware that there has been a significant increase in the number of persons convicted of sexual offences: this has resulted in increased demand for sex offender treatment programmes. To address this high demand, work is in progress nationally to increase the number of staff delivering sex offender group work. In the North West, the staff profile is increasing from 23 facilitators to 35. (These are full time equivalents: some of the new staff will also have offender management responsibilities as part of their role.) We envisage that the 11 new facilitators who are currently being trained will be in post by June 2018. A further 10 staff will then be trained and in post by the end of 2018. In addition, the North West Division is undertaking a scoping exercise for a central referral system to streamline the allocation process. | hope that the measures | have described above provide the assurance you are seeking of the National Probation Service's commitment to addressing the issue you identified in your report. Tin seus, ree Wn RICHARD HUGHES Head of Governance & Strategy 1 February 2018
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