Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0355, written 4 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Sep 2019 |
|---|---|
| Reference | 2019-0355 |
| Deceased | Imran Mahmood |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | State Custody related deaths · Alcohol, drug and medication 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 THIS REPORT IS BEING SENT TO: Dr J Farrar Chief Executive HM Prison and Probation Service 102 Petty France London SW/1H 9AJ CORONER 1 am Mr Andrew Haigh Senior Coroner for the coroner area of Staffordshire South 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 18 July 2018 | commenced an investigation into the death of Imran Mahmood aged 42 years. The investigation concluded at the end of the inquest on 4 September 2019. The conclusion of the inquest was drug related with the cause of death being morphine/heroin poisoning. CIRCUMSTANCES OF THE DEATH Imran was a serving prisoner found dead in his cell at HMP Dovegate on the morning of 16 July 2018. He had taken more heroin than his body could cope with. Imran had not engaged with the substance misuse team since 14 March 2018 because the drug he desired was not made available to him due to a national protocol. There was no knowledge of his drug use between 14 March 2018 to the time of his death. CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter 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 MATTER OF CONCERN is as follows — Imran had cooked the heroin he took by using the heating coil in an e- cigarette (vaping device). | have previously dealt with a prison death in similar circumstances. | am aware that prisoners should be allowed e-cigarettes should they want them. However they do present a danger not just by way of drug use but also the ability to start fires. | wonder if e-cigarettes used in the prison estate could be manufactured so that the heating component is in a sealed unit. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 30 October 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: Hudgells Solicitors for Imran’s family DWF Law Solicitors for Serco Care UK | have also sent it to the Prisons and Probation Ombudsman and the Independent Monitoring Board for HMP Dovegate 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. 4 September 2019 HM Senior Coroner for Staffordshire (South) Coroner's Office No 1 Staffordshire Place Stafford ST16 2LP Tel No: 01785 276127 sscor@staffordshire.gov.uk
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.
Pus a HM Prison & Probation Service Phil Copple Director General Prisons HM Prison & Probation Service 8" Floor 102 Petty France London SW1H 9AJ E-mail: directorgeneralprisons@justice.gov.uk Mr Andrew A Haigh Senior Coroner The Coroner's Court, No 1 Staffordshire Palace, Stafford, ST16 2LP E-mail: sscor@staffordshire.gov.uk 17 January 2020 Dear Mr Haigh, Inquest into the death of Imran Mahmood Thank you for your Regulation 28 Report of 4 September 2019 addressed to Dr Jo Farrar, Chief Executive Officer of Her Majesty’s Prison and Probation Service (HMPPS), following the inquest into the death of Imran Mahmood at HMP Dovegate on 16 July 2018. As you know, the report did not reach us immediately, and | am grateful to you for agreeing an extension to the statutory deadline for the submission of this response. | know that you will share a copy of this response with Mr Mahmood’s family and | would first like to express my sincere condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. | am grateful to you for bringing to my attention your concerns about the risks posed by the e-cigarettes available across the prison estate, with regard both to drug use and to fires. We are aware of these risks and continue to seek the safest options available. We are not in a position to fund the development and manufacture of these products, so we are limited to what is commercially available. We are also constrained by cost, as we are not permitted to subsidise sales to prisoners and must offer products that are affordable to them. However, we are currently considering alternative vape devices, including a new device that is not an e-cigarette and has no electronics, batteries, heat or vapour, instead using vapourless valve technology to deliver a low dose of nicotine. If and when we identify an alternative device that is suitable on security, safety and commercial grounds we will make it available across the estate. It should be noted that whilst there is information indicating that fires have been started by e-cigarettes, both accidentally through misuse, and with intent, our evidence shows that the number of cell fires has significantly reduced since the prison estate has gone smoke free. Thank you again for bringing this matter of concern to my attention. | trust that this response provides assurance that we are aware of the risks and taking action to mitigate them. Yours sincerely Phil Copple
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