Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0409, written 3 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Dec 2019 |
|---|---|
| Reference | 2019-0409 |
| Deceased | Luke Jones |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Alcohol, drug and medication related deaths · State Custody related deaths · Wales prevention of future deaths reports (2019 onwards) |
| 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.
John Adrian Gittins Senior Coroner for North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HMP Berwyn and the Ministry of Justice c/o A2 MOJ Private Law Litigation, Government Legal Department, One Kemble Street, London WC2 4Ts CORONER | am John Adrian Gittins, Senior Coroner for North Wales (East and Central) 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 the 34 of April 2018 | commenced an investigation into the death of Luke Morris Jones (DOB 4.10.95 DOD 31.3.18) The investigation concluded at the end of the inquest held with a jury on 29"" November 2019. The conclusion of the inquest was that it was a “drug related death in circumstances where a systemic failure in HMP Berwyn’s systems for preventing drugs entering the prison contributed”. The cause of death was recorded as being 1(a) Ventricular Cardiac Arrhythmia (b) Due to taking a synthetic cannabinoid CIRCUMSTANCES OF THE DEATH Luke Morris Jones was a prisoner at HMP Berwyn. On the 31° of March at around 18.08 he was found unresponsive in his room after smoking a novel psychoactive substance and despite medical intervention this resulted in his death which was confirmed at the Maelor Hospital Wrexham 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. — The report of the Prisons and Probation Ombudsman highlighted that there were concerns regarding the accessibility of drugs within HMP Berwyn and notwithstanding that certain measures had been taken at HMP Berwyn (namely in relation to the installation of a Rapiscan to test some of the incoming mail), evidence at the inquest confirmed that the continuing availability and use of novel psychoactive substances. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 By way of example, the evidence of the prison GP indicated that at least one instance of a prisoner being intoxicated was reported to him each day which he worked and as a result | consider it highly probable that the combination of the accessibility of NPS and the significant risks which they pose to health will be the cause of future deaths at the prison. 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 29" 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the Family of the Deceased lam 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 telease or the publication of your response by the Chief Coroner. Dated 3rd December 2019 Signature Senior Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL1IS 1YN Tel 01824 708047
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.
Amy Rees Director General of Probation and Wales HM Prison and Probation Service 3rd Floor Churchill House Churchill Way Cardiff CF10 2HH e-mail: Mr John Adrian Gittins HM Senior Coroner for North Wales (East and Central) Coroner’s Office, County Hall Wynnstay Road Ruthin LL15 1YN 21 January 2020 Dear / Annwyl Mr Gittins, Thank you for your Regulation 28 Report of 3 December 2019 addressed to HMP Berwyn and Ministry of Justice, following the inquest into the death of Luke Jones at the prison on 31 March 2018. I am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS). I know that you will send a copy of this response to the family of Mr Jones and I would first like 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 concern about the continuing availability and use of psychoactive substances at Berwyn. I share your concern, and would like to assure you that we continue to work at both national and local levels to tackle the availability and use of psychoactive substances within our prisons. The national Prison Drug Strategy, published in April 2019, sets out the measures that we are taking. The core aim of this strategy and our surrounding activity is to reduce the impact of drugs and alcohol in prisons by restricting supply, reducing demand and building recovery. Each prison is required to use this and an accompanying guidance document, to develop a local strategy that, applies the national approach to their particular circumstances, setting out how they will minimise the supply of drugs to the establishment, and work to identify residents with drug and alcohol issues and provide them with a range of services to help them to overcome their substance misuse problems and lead healthier, crime-free lives both in prison and in the community. At a local level, in recognition of the dangers posed by the use of psychoactive substances, the Governor of Berwyn and the Regional Substance Misuse lead for HMPPS Wales have revised the prison’s Drug Strategy. This primarily focuses on restricting the availability of illicit items, ensuring that there are appropriate consequences for those found in possession, and offering appropriate support for dependent users. Sophisticated intelligence systems that are designed to reduce the supply of illicit substances into the prison involve collaboration with a range of HMPPS and Police colleagues. As you know, a Rapiscan machine is now in place which has vastly improved the detection of contraband items. The introduction of improved gate searching, changes in the supervision of domestic visits and support for safe detoxification of men on reception are all part of the prison’s efforts to limit the availability of drugs. The mandatory drug testing procedures have also been extended to cover two more psychoactive substance tests in line with national policy. The extended tests will help indicate if some of the emerging psychoactive substances presently not in the testing range of HMPPS are being used at Berwyn. Intelligence and information sharing is crucial to restricting availability, and the Governor can draw on the Regional Dedicated Search Team when there is intelligence to suggest that prisoners are involved in the drug culture. The consequences for those found in possession of illicit items should be a deterrent, and can include additional days being added to sentences. Any person suspected of substance misuse use is referred to the substance misuse service for support and prescribed clinical management using an agreed care pathway. The prison is also focusing on educating prisoners of the risks associated with the use of psychoactive substances, as part of its broader work to promote health and wellbeing. Thank you again for bringing your concerns to my attention, and I hope that this response provides assurance that action is being taken. Yours sincerely / Yn gywir Amy Rees Director General of Probation and Wales, HM Prison and Probation Service Cyfarwyddwr Cyffredinol y Gwasanaeth Prawf a Chymru, Gwasanaeth Carchardai a Phrawf EM
See every Prevention of Future Deaths report matching Alcohol, drug and medication related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.