Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0461, written 10 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 | 10 Dec 2019 |
|---|---|
| Reference | 2019-0461 |
| Deceased | Daniel Akam |
| Coroner | Georgina Gibbs |
| Coroner area | South Yorkshire (East) |
| Category | Mental Health related deaths · State Custody related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
CORONER’S COURT AND OFFICE
CROWN COURT
COLLEGE ROAD
DONCASTER DN1 3HS
MS N J MUNDY
H M CORONER
SOUTH YORKSHIRE (East District)
Tel: (01302) 737135
Fax: (01302) 736365
email:
hmc.doncaster@doncaster.gov.uk
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
. THE GOVERNOR OF HMP LINDHOLME
. HM INSPECTOR OF PRISONS
THE NATIONAL OFFENDER MANAGEMENT SERVICE
THE INDEPENDENT ADVISORY PANEL ON DEATHS IN
CUSTODY
PRISON OFFICERS ASSOCIATION
THE CHIEF CORONER
PEN
Oe
1 | CORONER
| am Georgina Gibbs, Assistant Coroner, for the coroner area of South
Yorkshire East.
4
2 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.
3 | INVESTIGATION and INQUEST
4. On 18" October 2019 | commenced an investigation into the death
of Daniel AKAM, aged 43 years.
2. The investigation concluded at the end of the inquest on 4"
December 2019.
3. The jury determined that the medical cause of death was 1a
Hanging.
4. The jury returned a combined conclusion of Suicide and a
Narrative Conclusion in the following terms: “namely that the lack
of an adequate third ACCT Case Review was considered to have
— possibly contributed to Daniel Akam’s death.”
4 | CIRCUMSTANCES OF THE DEATH
4. Daniel Akam had some history of depression and self-harm when
4
in the community. Whilst in prison, he had a history of low mood
and anxiety.
2. From 4! October 2018, Daniel Akam expressed that he was
receiving threats from other inmates, and was suffering acute
anxiety as a result. An ACCT was opened, and he was
subsequently moved to a different wing on 8" October 2018.
3. Three days prior to his death on 10" October 2018, he made
superficial cuts to his wrists and forehead, at which pointhe was |
put onto twice hourly ACCT observations. This frequency was to
continue until further amendment, save a further stipulation was
added following a third and final ACCT review the day before his
death, on 12" October 2018, that no observation should be more
than 35 minutes after the preceding observation.
4. However, this third ACCT review only lasted for between 5-7
minutes, no member of health care was present, and the
assessment wrongly concluded that Daniel Akam posed a risk of
harm to others rather than to himself. This was contrary to all his
prison records, with which staff conducting the review had not
sufficiently familiarised themselves. Furthermore, his worsened
mental state was not sufficiently conveyed to health care post
review [The jury concluded that the inadequacy of this third and
final ACCT review possibly contributed to death].
5. Daniel Akam was last seen alive on an ACCT observation at
approximately 8:45am on 13" October 2018.
6. The next ACCT observation due at approximately 9:15/9:20a.m.
was not performed [Although it was left as possibly contributory,
the jury did not find that this factor possibly contributed to death].
7. Daniel Akam was found unresponsive on the floor of his prison cell
with a rope ligature around his neck at 9:45a.m; and declared
deceased at 10:30a.m.
8. He was no longer attached to the ligature upon his discovery, and
it was not possible, then or subsequently, to identify the ligature
point in the cell; nor how he was able to have a rope in his cell at a
time when he was vulnerable to self-harm.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise
to concer. 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. —
Failure to carry out ACCT observations recorded in the ACCT log
(1) CCTV evidence in the inquest established that 18 observations on
Mr Akam were not carried out.
(2) The same 18 missed observations were recorded in the ACCT
document as having been carried out, when they had not been.
(3) Five different prison officers purportedly signed various of these
entries.
(4) Whilst the above missed observations occurred 24 hours prior to
Daniel Akam’s death and were not contributory, the purpose of
ACCT observations is to reduce the risk of suicide and self-
harm in a vulnerable prisoner. If necessary observations are
missed, the risk of suicide and self-harm amongst vulnerable
prisoners will likely increase.
(5) The fact that the five separate officers did not carry out
observations, when they recorded that they did, indicates that
the problem is systemic.
ACCT training for prison officers
(6) In addition, the evidence revealed that the prison officers did not
appear to know what their own obligations and responsibilities
were in relation to the ACCT procedure and processes. The
general evidential picture was that of inadequate ACCT training
for officers, who universally indicated that it would be helpful to
have refresher training.
(7) Unless adequate and repeated ACCT training is provided for all
officers, particularly for those junior and more inexperienced
officers, the lives of vulnerable prisoners will not be
safeguarded in accordance with the purpose of the ACCT
procedure.
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 3 February 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 following
Interested Persons:
1. Care UK.
2.
3
| have also sent it to:
HM Inspector of Prisons.
The National Offender Management Service.
The Independent Advisory Panel on Deaths in Custody.
Prison Officers Association.
PONS
{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.
R
10! December 2019
\
GEORGINA GIBBS
ASSISTANT CORONER (SOUTH YORKSHIRE EAST)
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