Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0215, written 21 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jun 2019 |
|---|---|
| Reference | 2019-0215 |
| Deceased | Ryan Trimmer |
| Coroner | James Healy-Pratt |
| Coroner area | East Sussex |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Dr Jo Farrar, Chief Executive of HM Prison and Probation Service 1 CORONER I am James Healy-Pratt, HM Assistant Coroner for the area of East Sussex. 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 On 8 May 2017 I commenced an investigation into the death of Ryan Stephen TRIMMER, aged 29. The investigation concluded at the end of the inquest on 20 May 2019. The conclusion of the jury at the inquest was: Cause of death: I a. Hypoxic ischaemic brain injury I b. Hanging II. Emotionally Unstable Personality Disorder Narrative Inquest conclusion of: Ryan deliberately chose to attach a ligature to himself but did not intend that the outcome be fatal. The following matters caused or contributed to Ryan’s death; lack of phone calls, relationship, HMP Lewes prison staff resourcing on the healthcare wing, the complex nature of EUPD, inadequate ACCT reviews. 4 CIRCUMSTANCES OF THE DEATH (JURY FINDINGS) Ryan Trimmer was remanded to HMP Lewes on 4 March 2017. He had a history of self harm and suicide attempts. An ACCT was opened by reception staff. Ryan was found with a ligature around his neck on 4 March, 6 March and 20 April and he self harmed on 30 March. Ryan was found hanging in his cell on 22 April and he died in hospital on 26 April 2017. Ryan was on an ACCT throughout this entire period. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews. The Court heard evidence of the ACCT Pilot Scheme underway in certain other prisons. HMP Lewes should be considered as a priority facility for future extension of the ACCT Pilot Scheme. Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training. One frontline prison staff member gave evidence that he had not received training in 16 years of working for HMPS and felt he needed refresher training. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 August 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Ryan Trimmer HMP Lewes Sussex Partnership NHS Foundation Trust 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 James HEALY-PRATT Assistant Coroner for East Sussex Dated: 21 June 2019
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.
Phil Copple Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email: DirectorGeneralPrisons@justice.gov.uk James Healy-Pratt Assistant Coroner for East Sussex 28-29 Grand Parade, St Leonards-On-Sea TN37 6DR 12 August 2019 Dear Mr Healy-Pratt, Thank you for your Regulation 28 Report of 21 June 2019, following the inquest into the death of Ryan Trimmer at HMP Lewes on 26 April 2017. I am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS). I know that this response will be shared with the family of Mr Trimmer, and I would first like to express my condolences for their loss. The safety of those in our care is my absolute priority, and every death in custody is a tragedy. You have expressed concerns about the effectiveness of the Assessment, Care in Custody and Teamwork (ACCT) case management process, and about first aid training for prison staff. I am grateful to you for bringing these matters to my attention and I will respond to each of your concerns in turn. I note the findings of the jury with regard to the operation of the ACCT process in this case, and it is good to know that you heard evidence about the pilot of the revised version of ACCT. This took place in nine prisons and one immigration removal centre from February to June 2019. The feedback from the sites has been positive, and a formal evaluation of the pilot is currently being undertaken. The findings will inform the development of a new version of ACCT that we intend to begin to roll out nationally in early 2020. In support of this roll out there will be a clear communication strategy, and support mechanisms will be in place to help embed the revised process within each site. It is too early to give a firm date for the new process to be introduced at HMP Lewes, but we have noted your view that this should be a priority. Your second concern is that whilst prison staff can often be first on scene at a medical emergency, not all have received training in first aid. The Governors of each prison are required to ensure that there are sufficient numbers of staff trained in first aid on duty, and at HMP Lewes at least two trained nurses and one trained member of prison staff are available at all times. Two on-site first aid trainers will be delivering first aid training to staff as part of the prison’s monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior uniformed grade of staff) and Officer Support Grades (staff that support the duties of Prison Officers) have been provided with this training first, in order to ensure that those covering the Orderly Officer role (the person in charge of the operational running of the prison regime) and night duties are able to provide emergency first aid. The member of staff to whom you refer in your report is in this priority group, and will now receive refresher training. At a national level, since 2016 all new prison officers have completed a mandatory level 3 qualification in Emergency First Aid at Work as part of their Prison Officer Entry Level Training. This includes the application of CPR and the use of a defibrillator. Whilst there is currently no national requirement for all prison staff to be trained in first aid, we are currently reviewing the provision of first aid in prison, and we expect this to result in revisions to first aid policy and training. We have also been working with the Awarding Body on the development of a custodial First Aid awareness course, focusing on key areas and situations that may arise in the prison environment. Thank you again for bringing these matters of concern to my attention. I hope this response has provided assurance that they are being addressed. Yours sincerely, PHIL COPPLE Director General for Prisons
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