Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0056, written 6 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2020 |
|---|---|
| Reference | 2020-0056 |
| Deceased | Carl Newman |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and the Wirral |
| Category | State Custody related deaths · Suicide (from 2015) |
| 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 form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Mr Phil Copple, Director General Prisons HMPPS 102 Petty France London SW1H 9AJ 1 CORONER I am Andre REBELLO, Senior Coroner for the area of Liverpool and Wirral 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 11/10/2017 I commenced an investigation into the death of Carl John Newman aged 23. The investigation concluded at the end of the inquest held from the 2nd to the 6th March 2020. The jury conclusion of the inquest was: Carl John Newman died by suicide The medical cause of death was found as: I a Compression of the neck I b Hanging I c ------------------ II ------------------- 4 CIRCUMSTANCES OF THE DEATH The Jury found: During admission to 68 Hornby Road, Liverpool on the 3rd October 2017 the Person Escort Form indicated that there was no immediate self-harm risks to Carl John Newman, also the Cell Sharing Risk Assessment concluded there was more of a risk to others as opposed to himself. Further, a medical assessment filed by the Mental Health Nurse also drew the conclusion that there was no current risk to himself. The majority of witness statements indicate that Carl Newman was not distraught during his time in the Induction Unit. After 3rd October 2017, there was no known indicators of risk. However, the Day Two Assessment had not been completed in a timely manner, which may have flagged any potential risks. Between the hours of 9.26am and 9.53am on the 6th October 2017, texts were received and statements indicate that calls were also exchanged between Carl and his former partner. On the 6th October 2017 between the hours of 9.30am and 11.30am, a ligature was fashioned around Carl Newman's neck in the toilet area of cell A5/11. with the intention of ending his life. It is believed Carl John Newman initiated this act 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) During the Course of evidence it became apparent that prison staff did not have ready access to training records in particular ACCT & SASH training – one officer engaged in prison reception processes had not had ACCT training for over three years – and surprisingly it was another three years before he underwent SASH training. As HMP Liverpool were present throughout this investigation, the court understands that these training issues are being resolved locally. However this is a national issue and It is important that not only should HMPPS hold training records for those employed in the prison service but that each individual should have a personal training record. It would help if training certificates with expiry dates were issued after all courses with a copy being given to attendees and the record being held by the prison service. This would ensure all officers with current training could work across the prison estate, adding resilience. What does HMPPS intend to do to ensure that all officers and staff have current training in ACCT and other safer custody processes? 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 01 May 2020. 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 The family of Carl John Newman HMP Liverpool Spectrum – Healthcare Care provider at HMP Liverpool I have also sent it to The Prison and Probation Ombudsman and HM Inspectorate of Prisons Both at Third Floor, 10 South Colonnade, London E14 4PU who may find it useful or of interest. 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 Andre REBELLO Senior Coroner for Liverpool and Wirral Dated: 06 March 2020
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 & Probation Service
8th Floor 102 Petty France
London
SW1H 9AJ
DirectorGenralPrisons@justice.gov.uk
Mr Andre Rebello
Senior Coroner for Liverpool and Wirral
Gerard Majella Courthouse
Boundary Street
Liverpool L5 2QD
27 October 2020
Dear Mr Rebello
Thank you for your Regulation 28 Report of 6 March 2020, following the recent
inquest into the death of Carl Newman at HMP Liverpool on 6 October 2017.
I know that you will share a copy of this response with Mr Newman’s family and I
would like first 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 expressed concern that evidence given during the inquest indicated that staff at
HMP Liverpool were unaware of how to access their personal training records, and
suggested that this may also be an issue in other prisons. You also asked what
actions HMPPS is taking to ensure that all staff have up to date training in ACCT and
other safer custody processes.
All training courses – both those organised centrally by the national Learning and
Development team (including ACCT case manager training) and those provided
locally at establishment level (including the various modules of the Introduction to
Suicide and Self-Harm Prevention training) – are recorded on myLearning, the
HMPPS national learning database. Staff enrol on a course using this system, and
on successful completion of the training, their record is updated to reflect their
attendance (and pass/fail outcome for some courses). Both the learner themselves
and the local training department have access to this record. Training departments
are also able to run a report to see who has attended and/or passed a particular
course, and when. We consider that this electronic system achieves the same
outcomes as the system of certificates with expiry dates that you mention in your
letter.
As a result of the matters that arose at the inquest, the Governor of HMP Liverpool
has issued a staff information notice to promote the use of the myLearning system,
and staff have been reminded that they are able to view their personal training
records on it. This notice reiterates the importance of staff knowing when they need
to undertake any future refresher training and will shortly be followed up with a
comprehensive guide on how to use the system. There is also a local training co-
ordinator who is available to assist staff with queries about these issues, and has
responsibility for ensuring that staff are able to attend refresher training as required.
As you know, we intend to roll out a new version of the ACCT case management
system soon, and we will be taking this opportunity to update the related training
packages, and to refresh our approach to safety training more broadly. This will
allow us to reduce duplication between courses whilst ensuring that the content is
consistent and makes appropriate links between related issues. As we develop this
new set of training materials we will ensure that expectations as to which staff should
attend which courses, and the frequency of refresher training, are clear.
Thank you again for bringing these matters of concern to my attention. We will
ensure that learning from this tragic incident is shared widely across the prison
estate.
Yours sincerely
Phil Copple
Dierectot General- Prisons
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