Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0065, written 9 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 | 9 Mar 2020 |
|---|---|
| Reference | 2020-0065 |
| Deceased | Robert Brown |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Alcohol, drug and medication related deaths · State Custody 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.
Her Majesty's Coroner Staffordshire (South) Coroner's Jurisdiction Date: 9 March 2020 Case: 150458 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1. THIS REPORT IS BEING SENT TO: Michael Spurr National Offender Management Service, Clive House , 70 Petty France, London, SW1H 9AJ 2. CORONER | am Andrew A Haigh HM Senior Coroner for 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. 3. INVESTIGATION and INQUEST On 28 December 2018 | commenced an investigation into the death of Robert Anthony BROWN. The investigation concluded at the end of the inquest on 6 March 2020. The conclusion of the inquest was ‘Accidental death’ with the cause of death given as: 1a Aspiration of Gastric Contents 1b Synthetic cannabinoid receptor antagonists (5F-ADB) 4.CIRCUMSTANCES OF THE DEATH 3a Basic Circumstances: Robert Brown a prisoner at Dovegate was pronounced dead at 9:33 within his cell from drug use on 25th December 2018. 3b Probable Causes: Despite contact with drug misuse staff Robert could not stop taking illicit drugs. 3c: Possible Causes: The evidence did not disclose any possible causative factors. 5. 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. — Although there was no finding by the Jury that this was causative in respect of the death at times during the inquest it appeared that information in the central NOMIS records, information in the medical System 1 records and information available to the security department at the prison was not available to all staff at the prison who may have benefitted from having it. | did hear helpful evidence from the Head of Safer Custody a ct nationally efforts are being made to develop a system whereby significant 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk relevant information about a prisoner is available to all staff. There is however no timescale for this. It strikes me that this would be very helpful and might prevent deaths in the future. i wonder if you can give me a progress report about this planned development and an indication as to when it might be implemented. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to tak« 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 27.04.2020 |, 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. 8.COPIES and PUBLICATION i have sent a copy of my report to the Chief Coroner and to the following Interested Persons: e Mills Reeve — Solicitors for Care UK and MPFT e¢ DWF Solicitors - for Serco e Southerns Solicitors — for the family | have also sent it to the Prisons and Probation Ombudsman and the Independent Monitoring Board at 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. 9 March 2020 AoA be Andrew A Haigh Senior Coroner for Staffordshire South 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: 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.
Phil Copple Director General Prisons HM Prison and Probation Service 8" Floor Ministry of Justice 102 Petty France | London SW1H 9AJ | | H M Pri son & Email:DirectorGenetalPrisons@justice.gov.uk Probation Service Mr Andrew A Haigh Senior Coroner for Staffordshire South | Coroner’s Office : 1 Staffordshire Place Stafford ST16 2LP 15 May 2020 Dear Mr Haigh, Thank you for your Regulation 28 Report of 13 March 2020 addressed to Mr Michael Spurr following the inquest into the death of Robert Anthony Brown at HMP Dovegate on 25 December 2018. Mr Spurr is no longer in post, and | am responding as Director General of Prisons. | am grateful to you for granting an extension to the statutory deadline for my response. : | know that you will share a copy of this response with Mr Brown's family, and | would first like to express my condolences for their loss. The safety of those in our cate i is my absolute priority, and every death in custody is a tragedy. Your report expressed concern about information sharing between prison dnd healthcare staff, and you asked for a progress report on the plans to develop a new system that was described in evidence that you heard at the inquest. As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement, and they are leading on work with HMPPS to implement inter-operability between SystmOne and NOMIS, in order to enable better sharing of information between prison and healthcare staff. This is a big project and there are three phases of implementation. Approximately fifty percent of the planned development work on phase one, which is automating patient administration data sent from NOMIS to SystmOne, has been completed. Unfortunately, further work on this initiative has been temporarily halted by Total Phoenix Partnership (TPP), the supplier responsible for SystmOne, who have been directed to focus on COVID-19 related work. This will cause a delay, currently estimated at 8 weeks, meaning delivery of the completed phase one work is now forecast for August 2020. The sharing of risk information between NOMIS and SystmOne will form part of phase three of the project implementation, and it is forecast to be completed in 2021. if you would like any further information or updates on the project, then | would suggest contacting NHS England and NHS Improvement, as they are the lead organisation for the implementation process. While this IT project is underway, and forms an important part of the solution to the challenges presented by the information sharing in the prison environment; work is also being done at a local level to ensure that prison staff and NHS staff work tagether more effectively. At Dovegate, the Safer Custody Zone was formed in 2019 to provide an area in which prison staff, the Mental Health Team and the Integrated Substance Misuse Team are able to work together each day to ensure that key information is routinely shared. The introduction of the new system will further enhance this collaborative work and will enable information to be readily accessible to all staff. Thank you again for bringing your concerns to my attention. | trust that this, response provides assurance that local action is being taken to address the matter and that, whilst currently temporarily on hold because of immediate work related to the pandemic, progress is being made on the project to improve the sharing of risk information. | Yours sincerely, Po Cape. PHIL COPPLE Director General of Prisons
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