Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0014, written 15 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 | 15 Jan 2018 |
|---|---|
| Reference | 2018-0014 |
| Deceased | Antony Coughtrey |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | Other 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.
for Bedfordshire & Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
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THIS REPORT IS BEING SENT TO: |
| HM Inspectorate of Probation
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| Manchester Civil Justice Centre
|| Bridge Street West
| Manchester M3 3FX
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| CORONER
i Tam Tom OSBORNE Senior Coroner, for the Coroner Area of Milton Keynes
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| 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. |
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INVESTIGATION and INQUEST
| On 6th October 2015 | commenced an Investigation into the death of Antony Richard |
| COUGHTREY aged 42 years. The Investigation concluded at the end of the Inquest on |
ithe 23 of October 2017. The conclusion of the Inquest was that Antony Richard |
, COUGHTREY died as a result of suicide but the Jury went on to find that there was a |
| failure to manage his Licence adequately and this had caused or contributed to his death. |
| The medical cause of death was: i
| 1 (a) Hanging ; l
ist Chronic Pancreatitis
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| CIRCUMSTANCES OF THE DEATH ee |
The circumstances of the death where that Antony COUGHTREY had been returned te |
| prison for Breach of his Licence, having been released after serving 23 years of a life
Senior Coroner, The Court Hovse, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fay 306-300-8267
| prison he hanged himself.
sentence when he had been charged with an assault upon his brother. Once back in
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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. that following a death of a prisoner who had been released on licence following a
life sentence, there was no internal investigation by the Probation Service or any
inquiry resembling a Serious Incident Review. They seem to have led to an air of
complacency as to the Probation Service’s role in managing Mr Coughtrey
| 2. lalso felt there was a failure in the procedure for referring a prisoner back to the
Parole Board when there had been a clear breach of the Conditions of Licence set |
out by the Parole Board.
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|§ | ACTION SHOULD BE TAKEN
| In my opinion action should be taken to prevent future deaths and I believe you have the
| Power to take such action
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| You are under a duty to respond to this report within 56 days of the date of this report.
| namely by 15'* March 20181, the Coroner may extend the period. \
YOUR RESPONSE
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| Your Response must contain details of action taken or proposed to be taken, setting out i
| the timetable for action. Otherwise you must explain why no action is proposed. |
| COPIES and PUBLICATION
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' Persons (as per the attached list).
| Lam also under a duty to send the Chief Coroner a copy of your Response.
I have sent a copy of my Report to the Chief Coroner and to the following Interested |
The Chief Coroner may publish either or both in a complete or redacted or summary
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2X
Tel 9300-300-6559 | Fax 0300-306-8267
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.
eS
‘/Tom OSBORNE
Dated 15" January 2018.
Senior Coroner
Milton Keynes
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire. MK45 2HX
Tei 0306-300-6559 | Fax 300-300-8267
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