Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0182, written 31 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 May 2019 |
|---|---|
| Reference | 2019-0182 |
| Deceased | Joshua Blackham |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Classification: OFFICIAL-SENSITIVE REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (@3) THIS REPORT IS BEING SENT TO: Chief Constable Gavin Stephens — Chief Constable Surrey Police: Office of the Police & Crime Commissioner for Surrey, PO BOX 412, Guildford, Surrey, GU3 1YJ CORONER Tam Mrs Heidi J. Connor, Senior Coroner for the coroner area of Berkshire. a 2. | CORONER’S LEGAL POWERS T 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 I conducted an Inquest into the death of Joshua Blackham which was heard at Reading Town Hall between 13" and 20 May 2019. The jury recorded their conclusion as follows: Medical Cause of Death: 1a Asphyxia due to hanging. Narrative Conclusion On the evidence heard the Jury have come to the conclusion that Joshua _Olj ackham, on 29" November 2016 at [i acid take his own life by suicide and in the opinion of the Jury the following principle [SIC] factors contributed to Joshua’s death: 1) Joshua’s personal circumstances were multiple and complex in the period leading up to his death. Each of these circumstances will have placed significant stress on Joshua and in combination are likely to have contributed to his decision to end his life. -[- Classification: OFFICIAL-SENSITIVE Classification: OFFICIAL-SENSITIVE coe 2) The welfare system within Surrey Police at the time of Joshua’s arrest was insufficient. Although a welfare officer was appointed quickly, overall governance, policy, process and training were inadequate to provide the welfare support Joshua needed. Information sharing between all stakeholders was insufficient to keep the welfare officer adequately informed and is likely to have contributed to a lack of support given to Joshua. 3) The administration, communication, controls and process in place within the NHS prior to Joshua’s death failed to provide him with the mental health support he was referred for by his G.P. 4. CIRCUMSTANCES OF THE DEATH The family asked us to refer to the deceased as “Joshua” at the inquest. I have reflected that request in this report. I circulated a detailed summing up of the evidence which was circulated and agreed amongst the legal representatives for the Interested Persons in this case. Brief Summary Joshua Blackham was a 30 year old police officer who was arrested at work and suspended from duty on the 12" September 2016. He was allocated a Welfare Officer on the same day. A risk assessment document was sent to the Deputy Chief Constable in order for the suspension of duty to be authorised. The risk (of psychological harm) was assessed as medium by an investigating officer. This officer gave evidence that he would almost always state that the risk was “medium”, for any officer suspended from duty. He never met Joshua and knew very little about his circumstances. We heard in evidence that the Welfare Officer did not receive any training to undertake this role. The only guidance provided to this officer was a document called a “specific point of contact” document which provided some limited information about what should be included in risk assessment forms. The Welfare Officer completed risk assessment forms on: a. 14" September 2016 b. 7" October 2016 c. 2! November 2016 d. 4" November 2016 e. 4" November 2016 (an amended version) 2- Classification: OFFICIAL-SENSITIVE Classification: OFFICIAL-SENSITIVE f. 17° November 2016. i Between the time of Joshua’s suspension from duty and his death, the Welfare Officer met Joshua face to face twice-both times at Starbucks in Staines. A detailed chronology is set out in my agreed summary of the evidence. It is correct to say that, as time went on, the number of risk factors in Joshua’s life increased. These included relationship breakdown, financial concerns and concerns about contact with his daughter. We heard that for operational reasons, the Welfare Officer did not have access to the database used by the Professional Standards Department during their investigation. Information relating to escalating concerns about Joshua was not always adequately communicated between PSD and Welfare Officer. We heard there is no central area or database for these concerns to be recorded By 28" November 2016, it became known that Joshua had previously considered and/or attempted taking his own life before, both by a previous hanging attempt in September 2016 and considering taking his own life when standing on a railway bridge. Attempts were made to contact the Welfare Officer that evening but he was off duty. There were no arrangements in place for a welfare contact in those circumstances. The Welfare Officer was not aware that, in addition, Joshua was due to be interviewed in relation to a new allegation on 29"" November 2016. Tragically, Joshua was found hanged on 29" November 2016. 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 could occur unless this action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: ~ It is fair to say that Surrey Police had begun work on improving policies and procedures relating to officer welfare before this inquest. There are now better policies in place regarding risk assessment, and how this should be managed. It is also noted that officers are only rarely suspended from duty whilst under investigation. There remain, however, a number of areas where there are no written policies in place in relation to the role of a Welfare Officer. I remain concerned that, given that Joshua died in 2016 and these policies are not yet in place, the impetus could be lost after the inquest. 3. Classification: OFFICLAL-SENSITIVE Classification: OFFICIAL-SENSITIVE A large number of concerns were raised during the course of this 6 day jury inquest. I have sought to focus on the areas that I consider are of key concern in this respect. These are: 1. Training ~ for Welfare Officers and those who supervise them. i 2. It was suggested in evidence that a cadre of specialised Welfare Officers would be more effective than appointing individual officers with line management responsibilities. The advantages of this arrangement will be that the specialised skills would be held within that cadre, and that an individual officer who has been suspended from duty may feel reluctant to discuss personal matters with a senior officer in his/her own management line. I consider this suggestion should be considered by Surrey Police. 3. Consideration should be given as to how communication of concerns between PSD and the Welfare Officer can take place more effectively. 4. Consideration should be given to the Welfare Officer contacting the family of the officer suspended from duty, to gain further information, where appropriate consent has been given. 5. Any new arrangement should make allowances for contact with a Welfare Officer where the primary Welfare Officer is off duty. 6. There should be a written policy as to the location of the arrest of a serving officer, so as to reduce the impact of this on his/her welfare. 6. | ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe your organisation has 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 26" July 2019. 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. Classification: OFFICIAL-SENSITIVE Classification: OPFICIAL-SENSITIVE 8. | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to Joshua’s legal | representative. Tam 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. | 31 May 2019 a Mrs Heidi J. Connor Senior Coroner for Berkshire 5. Classification: OFFICIAL-SENSITIVE
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.
OFFICIAL SENSITIVE Regulation 28: Report to Prevent Future Deaths – Joshua Blackham Document details Authorising Officer Chief Constable Gavin Stephens Author Chief Superintendent Completed: 21/7/19 Distribution HM Coroner Mrs Heidi Connor Executive Summary: This report has been written in response to actions outlined within section 6 of the coroners regulation 28 report following the investigation and inquest into the death touching Joshua Blackham. HM Coroner’s request for response to key areas of concern as follows: 1. Training – for Welfare Officers and those who supervise them. 2. It was suggested in evidence that a cadre of specialised Welfare Officers would be more effective than appointing individual officers with line management responsibilities. The advantages of this arrangement will be that the specialised skills would be held with that cadre, and that an individual officer who has been suspended from duty may feel reluctant to discuss personal matters with a senior officer in his/her own management line. I consider this suggestion should be considered by Surrey Police. 3. Consideration should be given as to how communication of concerns between PSD and the Welfare Officer can take place more effectively. 4. Consideration should be given to the Welfare Officer contacting the family of the officer suspended from duty, to gain further information, where appropriate consent has been given. 5. Any new arrangement should make allowances for contact with a Welfare Officer where the primary Welfare Officer is off duty. 6. There should be a written policy as to the location of the arrest of a serving officer, so as to reduce the impact of this on his/her welfare. Surrey Police response (In respect of the order in which the points appear above): 1. The Force has agreed to provide training and refreshed guidance for any officer/staff member who is assigned as Welfare Officer (previously referred to as Wellbeing and Support Officers). Surrey Police’s Learning and Development Department are in the process of creating a short video which will fully explain the Welfare Officer (WO) role which all WOs, on being assigned the role, will watch as part of a full guidance package. This package will include revised Welfare Officer Guidance documentation. This is anticipated to be finalised by the end of August 2019 with all Senior Management Teams across the Force being briefed from September 2019. Under the new process all WOs, will be assigned a lead from their Senior Management Team (SMT) who will be responsible for briefing the WO on their role using the new material and will then remain as point of contact for the WO offering support and guidance. They will ensure that risk assessments are completed in a timely fashion, providing suitable oversight and scrutiny. The Duty of Care Risk Assessment (DOCRA) is being re‐written and will be the only document used to record risk to an individual and the steps being taken to mitigate that risk. [This replaces the risk assessment document which was used in Joshua’s case]. The DOCRA will be updated every 28 days as a minimum (or more frequently as the risk requires) and will be sent by the WO to their SMT lead for comments. Oversight of all persons who are subject to a DOCRA will become a standing agenda item at each monthly SMT meeting thereby ensuring that there is oversight of all cases, regardless of risk level. 2. A cadre of specialised WOs has been considered in more detail by the Force since the inquest but the Force has made the decision not to pursue this on the grounds that it is not practical and may not be in the person’s best interest. Having a cadre limits the number of people undertaking the role and it is also important that the person involved has a say in who their WO is, which may not include anyone within a cadre. The Force felt that the selection of a WO should be considered by the relevant SMT for the area/department where the person works and that with the introduction of training, revised guidance and managerial oversight a cadre of specialists was not necessary. 3. As to ensuring that all concerns about a person held by PSD, Federation, Unison or otherwise are available to the WO in completing their risk assessment, the new process will ensure that the DOCRA is completed having directly contacted all relevant parties. The default position will be that all information will be shared unless there is a specific reason not to do so which should be recorded with suitable justification. This way no relevant information is invisible to the WO. The new guidance is also accompanied by a simple visual flowchart for WOs as a reference document. 4. The matter of a WO considering contacting the family of an officer suspended from duty has been included in the revised guidance. 5. Having a secondary (back up) WO has been included in the revised process to ensure that there is suitable cover for annual leave or other absence. Contact details of all relevant persons supporting the particular officer/staff member will be listed at the front of the DOCRA. 6. Consideration about the location of the arrest of a serving officer so as to reduce the impact on his/her welfare has been included within the relevant PSD guidance policy.
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