Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0374, written 30 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Nov 2018 |
|---|---|
| Reference | 2018-0374 |
| Deceased | Bradley Brown |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ministry of Justice, London 2. NHS England, Skipton House, 80 London Road, London SE1 6LH CORONER | am Ms L Hashmi, HM Area Coroner for the Coroner area of Manchester North. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On the 16" August 2017 | commenced an investigation into the death of Mr Bradley Fraser Brown. The investigation was concluded by way of inquest (sitting with a jury) on the 31% October 2018. The jury reached a narrative conclusion, which included that the deceased had taken his own life by way of self suspension, on the balance of probabilities. CIRCUMSTANCES OF DEATH At the time of his death Mr Brown was a serving prisoner. He had been transferred to the prison (where he subsequently died) late on the afternoon of Friday an August 2017. Upon arrival, it was too late for Healthcare to conduct its initial assessment. A brief mental health assessment was carried out but the Nurse did not have access to Mr Brown’s full records. The IMR was not transferred with Mr Brown as Healthcare at the transferring prison had not been made aware of the plan to move him. Whilst Mr Brown had a past history of paranoia and drug misuse, the Mental Health Nurse's assessment did not give rise to any cause for concern. Mr Brown declined referral to the menta! health team. For clarity, he was not subject to an ACCT. He was placed in a single occupancy cell on the induction wing. Mr Brown did not attend his first healthcare screening assessment appointments on the 12/13" August. Over the course of the weekend, he participated in periods of association etc. and did not raise any concerns. He appeared settled but quiet. On the night of the 13" August 2017, an Operational Support Grade Officer (OSG) was allocated to patrol to induction wing as part of her duties. The first roll count was completed without issue. The OSG had no cause to visit Mr Brown’s cell during the course of her shift. There had been problems with the OSG's ‘pegging’ on the wing during the night. In the early hours of the 14” August, Prison Officers discovered the OSG asleep on-duty. This was escalated to the duty manager who reprimanded her. He did not report the incident to the duty Governor and did not record the incident. At around 06:30-06:45 on the morning of the 14" August the OSG carried out the morning roll count. When she checked Mr Brown’s cell she noted that the observation panel had been obscured by a piece of material. She could not see Mr Brown and she did not try to vocalise with him because she heard what she believed to be a noise coming from within. She did not report/escalate the matter. At around 07:30 the oncoming Prison Officer noted that the observation panel was blocked and attempted to speak with/see Mr Brown. When he looked down the side of the cell door he could only see the front of him. Suspecting something untoward had happened, he called a colleague over. When they entered the cell, they found Mr Brown suspended by ligature from the light fitting. Mr Brown was cut down, CPR commenced and a ‘code blue’ called. Despite best efforts, Mr Brown could not be resuscitated and the fact of his death was confirmed by attending Paramedics later the same day. 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, Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted. There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe. The same concern applies, in principle, to public/bank holidays. There are different levels of healthcare at the weekends as compared to weekdays. This gives cause for concern given the inherent susceptibilities with which prisoners frequently present. Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known). By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities) timely risk assessment is critical in the prevention of self-harm leading to death. Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner's full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database. There is no national guidance in relation to late transfers/'cut-off points etc. 2. Commissioning of Mental Health/Healthcare Services: As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action. These issues are not unique to the Prison involved in Mr Brown's case. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 the 25" January 2019. |, 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:- - Mr Brown's family -__HMP via the Government Legal Service - Greater Manchester Mental Health ((GMMH’) 1am 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 from. 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. 19 [Date: 30" November 2018
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.
) o x ae HM Prison & Probation Service Michael Spurr Chief Executive HM Prison & Probation Service 8 Floor 102 Petty France London SW1H 9AJ Email: Ms L Hashmi Area Coroner for Manchester North H M Coroner's Office The Phoenix Centre L Cpl Stephen Shaw MC Way Heywood OL10 1LR 01 February 2019 Dear Ms Hashmi, Thank you for your Regulation 28 Report of 30 November 2018 following the recent inquest into the death of Bradley Fraser Brown at HMP Buckley Hall on 14 August 2017. | know that you will share a copy of this response with Mr Brown’s family and | 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. You have expressed concerns about the transfer of prisoners between prisons on a Friday and at weekends and how this may impact on the level of care and support available to them, particularly in respect of Healthcare and Mental Health assessments. | understand that NHS England will also be responding directly to your concerns in terms of their healthcare processes and will explain that the new specification for the provision of healthcare at Buckley Hall will include access to mental healthcare 7 days a week. . | know that you will appreciate the importance of being able to move prisoners around the estate, both to manage population pressures and to ensure that prisoners are located in the appropriate category of prison. Inter prison transfers currently take place from Monday and Friday in accordance with a schedule agreed with the Prison Escort Court Service (PECS). Removing Friday from the schedule would put undue pressure on the remaining four days and increase the risk of late arrivals on those days. Prisons are always given advance warning of these scheduled transfers and PECS notify establishments of their anticipated arrival times, so that arrangements can be made. In terms of weekends, whilst there is provision at a national level for inter prison transfers to be facilitated on a Saturday or Sunday, this will only be done under exceptional circumstances and is extremely rare. Transfers generally only take place over a weekend when an emergency at one prison necessitates a move of prisoners to a different establishment. However, as a result of the concerns you have raised, the Governor at HMP Buckley Hall has instructed all Governors at the establishment that they should not enter into local agreements to accept transferred prisoners on a Friday. This will be reviewed O once the changes to the provision of healthcare have been embedded. In addition, a range of measures has been implemented to ensure that all new arrivals receive the same level of care regardless of when the transfer takes place. First night procedures have been strengthened to ensure that all prisoners arriving at the prison are subject to a 72 hour period of monitoring, which includes randomly spaced welfare checks during lock up periods. A Challenge Support and Intervention Plan (CSIP) is opened for any new prisoners who have been subject to a period of segregation prior to transfer. This provides for a period of monitoring to ensure that vulnerability or violence is managed appropriately. Healthcare staff have also been instructed to notify the Orderly Officer if any prisoner misses an appointment in the early days, so that reasons for non-attendance can be followed up. If a prisoner refuses to attend, Healthcare will be informed and the actions taken recorded by prison staff. Prior to any transfer there is a requirement for Healthcare staff at the sending establishment to assess each prisoner to ensure that any health concerns are recorded and communicated to the receiving prison and to confirm that the prisoner C) is medically fit to be moved. A notice has been issued to all staff at HMP Haverigg, “ which was the transferring prison in Mr Brown's case, reminding them to confirm to Healthcare staff any transfer, so that medical records are reassigned promptly in order that they are immediately available when the prisoner arrives at the new establishment. Thank you again for bringing these matters of concern to my attention. We will ensure that learning from this tragic incident is shared widely across the prison estate. Yours sincerely Hichoe’ Spurr Michael Spurr
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