Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0398, written 19 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Nov 2019 |
|---|---|
| Reference | 2019-0398 |
| Deceased | Shaun Dewey |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Suicide (from 2015) · State Custody related deaths |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 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.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon 19th November 2019 : ; REF: 10521 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Phil Copple Director General — Prisons HM Prison and Probation Service 102 Petty France Westminster SW1H 9EX CORONER | am M E Voisin Senior Coroner for the Area of Avon 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 09/05/2018 | commenced an investigation into the death of Shaun William Dewey. The investigation concluded at the end of the inquest 18th November 2019. The inquest was held with a jury who found that ... “Shaun William Dewey died on the morning of the 13th April 2018 in his cell on.'A' Wing at HMP Bristol from compression of the neck, having suspended himself from a ligature tied to the bed frame. Shaun's own anxiety, depression and separation from his family, was exacerbated by uncoordinated supervision and erratic medication use. These were all contributory factors to his state of mind and ultimately his death. , Although there were prison, health-care and mental health care systems in place to safeguard Shaun, they were insufficiently applied to prevent his death.” The conclusion of the jury was recorded as: “Suicide - with narrative. Although Shaun's presentation did not necessarily signify his intent, there were instances during his remand when the systems in place failed to identify issues and act upon them, for instance a previous significant act of self-harm, which was not highlighted or picked up on, during transfer from HMP Hewell. On occasions when signs were identified, there was failure to act sufficiently and there was a tendency to close actions, before issues were fully resolved. Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL In the last weeks of Shaun's life the Jury believes there were sufficient signs to warrant the opening of another ACCT.” : CIRCUMSTANCES OF THE DEATH The deceased who was a remand prisoner was found hanging in his cell at HMP Bristol. 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. — During the inquest | was made aware of 2 reports the first was The Prisons and Probation Ombudsman — “Learning from PPO Investigations, Risk Factors in self-inflicted deaths in prison” published in April 2014 which was a review of deaths investigated between 2007 and 2013 and stated: © On page 12 of the report paragraph 3.1 “... remand prisoners ... made up 43% of the deaths ... but are only 13% of the total prison population” © onpage 21 of the report paragraph 5.5 “...it is surprising remand is not specifically highlighted in the current context section of the list of risk factors of PSI 64/2011” Next I was referred to a Ministry of Justice document published 31% January 2019 “Safety in Custody Statistics, England and Wales: Deaths in Prison Custody to December 2018 Assaults and Self-harm to September 2018” this report on page 9 states “Prisoners who were in custody serving indeterminate sentences .... or were on remand (2.91 per 1,000 prisoners) had a higher rate of self-inflicted deaths than all determinate sentences ..” My concern is therefore whether the risk of remand prisoners being at higher risk of self-harm or suicide should be: e considered by those designing the training for staff; e a factor generally highlighted to those caring for prisoners including prison staff and healthcare teams that is both the mental and physical health teams. e —arisk highlighted on the ACCT document or e reflected in any re-draft of PSI 64/2011 national guidance — “Management of prisoners at risk of harm to self, to others.and from others (safer custody)” ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 17th January 2020 . |, 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. Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL COPIES and PUBLICATION | have sent a copy of my report to the chief coroner and to the following interested persons e Family e HMP Bristol e Bristol Community Health e Avon & Wiltshire Mental Health NHS Trust a 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 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. 19/11/2019 Signature —_ ME Voisin Senior Coroner Area of Avon Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
HM Prison & Probation Service Ms Maria E Voisin HM Senior Coroner for the Area of Avon The Coroner's Court Old Weston Rd Flax Bourton BS48 1UL Dear Ms Voisin, Phil Copple Director General Prisons HM Prison and Probation Service 81h Floor Ministry of Justice 102 Petty France London SW1 H 9AJ Email:DirectorGeneralPrisons@justice.gov.uk 31 January 2020 Thank you for your Regulation 28 Report of 19 November 2019 following the inquest into the death of Shaun Dewey at HMP Bristol on 13 April 2018. I am grateful that you granted an extension to the statutory deadline for my response. I would first like to express my condolences to the family and friends of Mr Dewey for their loss. The safety of those in our care is my absolute priority, and every death in custody is a . tragedy. You have drawn attention to the fact that prisoners on remand are at a higher risk of self- harm and suicide, and have asked that we give consideration to recognising remand status as a risk factor in national policy and guidance, and in the training provided to staff. As you rightly point out, whilst Prison Service Instruction (PSI) 64/2011 Safer Custody contains lists of identified risks and triggers for suicide and self-harm that include factors that are relevant to many remand prisoners (such as early days in custody), it does not mention remand status itself. However, we frequently supplement the list in the PSI with additional information for staff, and this has included references to the increased risk posed by remand prisoners. For instance, the April 2014 Prison and Probation Ombudsman learning bulletin, from which you have quoted in your report, was disseminated widely within prisons, and more recent guidance issued by our prison safety team and made available to staff on the HMPPS intranet includes. remand status as a risk factor for suicide. Training based on this more recent guidance has also been provided to staff in a number of prisons. During 2020 we will be replacing PSI 64/2011 with a policy framework on prison safety, and as part of this process the lists of risks and triggers will be reviewed and updated. We will ensure that the evidence about the risks posed by remand status, which you have drawn to my attention, is used to inform that work. The new policy framework will include a new version of the Assessment, Care in Custody and Teamwork (ACCT) process designed to make the system easier to operate and improve the quality of care offered to prisoners, The new version of the form and associated guidance were piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal evaluation report and expect to make some further changes before the national rollout. I will ensure that your point about the need to bring attention to the risks associated With remand status is considered as we do so. We will also be revising the Introduction to Suicide and Self Harm Prevention training (a course that is undertaken by all staff with prisoner contact) to reflect and support the new policy framework and changes to ACCT. Again, we will use -this opportunity to ensure that the modu.le on recognising risks and triggers is reviewed and updated.· Thank you for raising your concerns with me. I hope that my response provides assurance that we are taking steps to ensure that staff understand the issues that you have identified, and that the risks involving remand prisoners are properly managed. Yours sincerely, PHIL COPPLE Director General for Prisons
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