Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0103, written 20 Apr 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Apr 2020 |
|---|---|
| Reference | 2020-0103 |
| Deceased | Andrew Jones |
| Coroner | Dr James Adeley |
| Coroner area | Lancashire and Blackburn with Darwin |
| Category | Alcohol, drug and medication related deaths · State Custody related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
for Lancashire & Blackburn with Darwen
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: National Offender Management
1
2
CORONER - I am Dr James Adeley, Senior Coroner for Lancashire & Blackburn with
Darwen
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 3 March 2020 I commenced an investigation into the death of Andrew Patrick
Jones aged 37 years at the time of his death. The investigation concluded at the end
of the inquest on Thursday, 19 March 2020. The conclusion of the inquest was a
narrative conclusion as set out on the attached document.
4
CIRCUMSTANCES OF THE DEATH
The circumstances of the death were fully set out in following attached documents:
• Summing up extending to 20 pages including questions to the jury
•
• Report of
, consultant psychiatrist
Jury conclusions
However, a brief synopsis was that Andrew Jones was a 37 year old male located on a
wing for vulnerable prisoners separated from the main prison wings. There was a
total failure of the Personal Officer Scheme with no entries being made in the 11
months prior to the death. After an altercation on 21 November 2018 he was
transferred off the wing when there was no regime in place to manage such transfers
and the reason for the transfer off the wing was inadequate. There was a failure to
discuss the case at the Population Management meeting to manage the risk before
transfer, there was a failure to reassess the changing circumstances caused after he
had come off an ACCT document from which nearly all the actions that are because
the self-harm had not been addressed, was transferred to the main prison regime
with no assessment of risk by the transferring Custody Manager, transferring Senior
Officer or receiving Senior Officer. The prisoner was then unlawfully detained on
segregation with the requirements of healthcare assessment removed and which did
not take place for the 33 hours prior to his death including a lack of regime of
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
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exercise, showering and a phone call. The unlawful detention had pre-existed the
date of death for approximately three years across almost every wing in the jail and
may have been applied to 6-700 prisoners, the number being unable to be
ascertained due to a lack of prison records. The adjudication that should have taken
place the following day did not occur and there was a failure in prison
communication to inform the prisoner of this occurrence. Due to differing medication
regimes on the wings, with no adequate explanation for this difference, Andrew
Patrick Jones had his mood stabilisation medication and tramadol for back pain
suddenly withdrawn without healthcare involvement. The expert psychiatric
evidence stated that the prison regime created "the perfect storm" and the jury
concluded that this contributed to the death and also added the rider of Neglect to
indicate the failure to provide basic care by the Prison Service.
5
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 and all share a central theme that the risk
averse nature of the prison service has been substantially reduced over the last 5-6
years to one in which risk is routinely ignored: –
(1) Assessment of risk Andrew Jones self-harmed on 26 October 2018 and
remained on an ACCT document until 12 November 2018. The principal
reasons identified by Andrew Jones for self-harming were that he had long-
standing back pain, which his tramadol (an opiate-based medication) was
being reduced by the prison GP, with which Andrew Jones did not agree, the
back pain was to be addressed by remedial gym and physiotherapy and
Andrew Jones did not cope well in his cell on basic regime. In summary, the
only factor that was identified to initiate the self-harm that was addressed
was the re-instatement of the normal IEP regime.
The Post Closure Review (PCR) was undertaken on 19 November 2018 by
Senior Officer
who had read the ACCT document before the review,
who was familiar with Andrew Jones and who was aware of the following:
• continuing back pain with reduction in pain relief but without
compensating medical treatment, which was either impossible to
deliver either due to the absence of any physiotherapy in the jail or
the failure by the prison GP to refer Andrew Jones for remedial gym;
that prisoners on the wing were
vulnerability in the main prison estate;
that the support of his brother and other prisoners on the wing was a
protective factor
located there due to their
•
•
identified a protective factor that Andrew Jones would speak to prison
staff if he felt like self-harming: Every officer who gave evidence indicated that
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
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Andrew Jones rarely, if ever, spoke to prison officers as he had previously been
accused of being a grass.
However, the Senior Officer who undertook the review did not make his entry into
the prison record until after the altercation had occurred on the 21 November 2018,
when Andrew Jones was now on basic regime, on a charge and had been transferred
off the wing. The Senior Officer accepted that he would have read the entry relating
to the altercation, noted the return to basic regime and transfer off the wing, which
immediately preceded his entry. This can be easily determined by looking at the
Cnomis entries. The Senior Officer accepted that he was the only person who would
have been aware of the substantial alteration in risk of self-harm for Andrew Jones,
that there was a substantial alteration in the risk profile, then made an entry in the
prison record reflecting only those events that were pertinent two days earlier and
prior to the altercation.
The Senior Officer, and the senior prison management accepted that there had been
a substantial alteration in risk with every protective factor now being converted into
a risk factor. Furthermore, it was accepted that there was a failure to warn the
receiving wing of the alteration in risk and that there was a further failure to reassess
the alteration in risk. The consistent evidence of the senior management was that an
ACCT should have been opened, healthcare would have been involved and the first
question that is always asked is "what medication is this prisoner on and is he taking
it"? This would have identified the fact that Andrew Jones was not receiving his mood
stabilising medication and, due to a lack of prescription of tramadol, would have
been withdrawing from the effects of opiates which combined with his psychiatric
condition of Emotionally Unstable Personality Disorder, produced a very significant
and ongoing increase in his risk of self-harm (See below). In addition, had an ACCT
been opened the approach to segregation would have been markedly different.
(2) No written protocol or common understanding undertaken regarding
deselection from the RSU relating to risk on transfer to a normal prison
said that transfer off the RSU was
wing: Custody Manager
appropriate, which was factually incorrect. The evidence of every governor
grade witness who dealt with the point was that the altercation was
insufficient to require the urgent transfer of Andrew Jones of the wing. This
action substantially raised the risk of Andrew Jones self-harming.
With regard to the protocol for deselection of a prisoner form the RSU, it was
the evidence at the inquest that the Number One Governor had given an
instruction that, as the RSU was the only discrete unit without wraparound
guidance on deselection, there should be a written regime. This was neither
Manager
followed up by the Governor
responsible for the RSU, neither of whom could provide a reasonable
explanation for the omission. At no time was there a written protocol for
deselection. There was a form but it appeared form the evidence of
nor by
on whom
relied, that this had never been used for
deselection of a prisoner from the RSU at the Population Management
Committee (PMC).
denied any conversation in which he had
said it was unnecessary to refer to the PMC.
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
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had discussed Andrew Jones deselection from the RSU in the
week before the altercation with the two SOs on the wing and that there was
no entry in any prison record to reflect the discussion or an assessment of
risk. To exacerbate the risk,
, the SO
on duty on 21 November 2018, was unfamiliar with the wing not having
worked there, had no prior knowledge of Andrew Jones and this reallocation
of SOs to specialist areas of the prison with no supervision was commonplace.
The only handover that was given by SO
on the RSU to the receiving
wing was that there were no non-associates and Andrew Jones was behind his
was unaware that
door on basic regime pending adjudication. SO
Andrew Jones had been on an ACCT until after he had been sent to C Wing.
was aware that
the SO on C Wing would have liked more
Finally, although SO
information, he neither asked the transferring wing SO for this nor
interviewed Andrew Jones when he arrived on C Wing. No adequate interview
was undertaken on C Wing of Andrew Jones before his death despite the fact
he was segregated nor were any distraction materials provided.
(3) Unlawful use of Segregation: In this case, the relevant segregation legislation
was Prison Rule 53 (4) which provides for segregation prior to an adjudication.
The guidance that accompanies Rule 53 (4) provides for an initial 4 hour
period of being placed behind the cell door after which the prisoner is de
facto segregated.
There was no legitimate reason to segregate Andrew Jones at all under Rule
53(4)as he could not collude or intimidate anyone as no one else was involved
in the altercation. In addtition, as soon as Andrew Jones was brought to his
feet, he remained calm and controlled until his death. It was accepted by the
senior prison staff that segregation was unavailable under this Prison Rule,
was unlawful and Andrew Jones should have been returned to the normal
wing regime at the end of four hours.
Unlawful use of segregation was routine practice since the introduction of the
new rules some 3-4 years earlier. at a This is a substantial understatement of
what was taking place at HMP Garth. Since the time of introduction, on a jail
wide basis, prisoners were routinely segregated behind their cell doors for
periods after the initial four hours had expired without any of the safety
features of segregation including assessment by healthcare to determine if
segregation would adversely affect the health of the prisoner, authorisation
by a Governor, regular checks et cetera. As a basic calculation on figures
provided by the prison, this would suggest that 6-700 prisoners were detained
in their cells by this method. Even after concerns were raised regarding the
application of Prison Rule 53 (4), an SO circulated emails to two wings
suggesting that it was appropriate to place a prisoner behind a door for four
hours by which time the end of the prison day had come and they could
continue behind the door; this was a practice discouraged in evidence at the
inquest. This use of segregation without healthcare involvement resulted in
the removal of Andrew Jones' mood stabilising medication and the cessation
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752
of his tramadol resulting in withdrawal symptoms occurring no later than the
evening of 21 November 2018. Finally, Andrew Jones was segregated without
even the benefits allowed to prisoners on the segregation unit of a shower, 30
minutes fresh air exercise and a telephone call each day.
The National Offender Management Service Specification for Prisoner
Discipline and Segregation provides that the Key Outcome(s) for Service are a
"safe, ordered and decent prison" and "the use of segregation in prisons is
lawful, safe and decent". By reference to the NOM documentation the
application of the rules was neither safe, lawful nor decent.
(4) Personal Officer Scheme: The Prison Service regime provides for a Personal
Officer, who is usually an officer on the wing whether prison is located, to
take a particular interest in the prisoner to achieve a greater knowledge of
that prisoner through interaction than a regular prison officers would have.
There is no indication in the prison records that any officer was appointed as
Andrew Jones' Personal Officer and there is no indication in any of the prison
records that any personal Officer interview or even time spent with Andrew
Jones was either ever attempted or undertaken. In a prisoner who is failing to
comply with the prison regime and attend work, possibly due, in Andrew
Jones' case, to increasing paranoia or back pain, there was no attempted
exploration of the prisoner's motivation for such behaviour and inconsistent
threats of consequence as to what would happen if he continued his
behaviour.
(5) Different medication regimes operated by prison staff on the wings: Andrew
Jones was not allowed to hold medication in possession due to a previous
overdose. Each morning and evening, he regularly collected his medication
and was compliant with receiving and taking his mood stabilising medication
(Quetiapine) and his analgesic (Tramadol). The system operated on the
Residential Support Unit (B Wing) was that prison officers shouted out to the
prisoners that medication was open and any prisoner that wanted to receive
medication then pressed his cell bell and was released. On C Wing, where
Andrew Jones was held in segregation, a list was delivered by Healthcare and
the prison officers did not shout but unlocked those that were on the list.
Consequently, because Andrew was transferred rapidly on the morning of 21
November 2018 he was not on the Healthcare list and was not unlocked: It is
presumed that he would have waited to hear prison staff call out that
medication was available. The first indication that Healthcare were aware
that Andrew Jones had transferred to C Wing was midday on 22 November
2018 when he would already have been experiencing a reduction in mood
stabilisation and significant symptoms from opiate withdrawal. There was no
adequate explantion of why prison wings operate different system for prison
staff to notify prisoners to collect their medication.
(6) Adjudication hearing: The altercation on 21 November 2018 should have
resulted in an adjudication on 22 November 2018. On 22 November 2018
there was an overrun of the adjudications on the morning of 22 November
2018. As no one had informed Andrew Jones, he asked the prison officer who
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
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attended him at midday on the 22 November 2018 what was happening.
Andrew Jones was taken out of his cell and after the information had been
obtained, informed that his adjudication was delayed. However, the message
from the prison governor undertaking the adjudications that the adjudication
would not occur that day and would be delayed to the following day did not
reach the wing and was not conveyed to Andrew Jones. This is a breach of
prison rules, did not detect that Andrew Jones was unlawfully segregated,
failed to covey information to him and also failed to detect he did not even
have the benefit of basic amenities such as a shower, a telephone call and
fresh air.
(7) Reliance upon medical reports that fail to address issues relevant to the the
death: The report by NHS England concludes that Andrew Jones' "physical
healthcare needs were appropriate and timely and his healthcare medications
were prescribed appropriately" and that Andrew Jones "received healthcare
equivalent to that which he could have expected to receive in the community".
This statement is almost entirely inaccurate and is based upon inadequate
medical evidence.
The report of the consultant psychiatrist,
attached to this
report provides an in-depth analysis of those matters affecting Andrew Jones
around the time of his death. These include the following:
a. due to Andrew Jones Emotionally Unstable Personality Disorder and
previous use of heroin, the reduction in his tramadol by the prison GP
would have resulted in particular difficulties and should have been
undertaken with Andrew Jones' agreement and in consultation with
the psychiatrist;
b. the reduction in tramadol occurred when the GP did not undertake a
referral for Remedial Gym and the prison had no physiotherapist to
deliver any care. The result was a reduction in pain medication
without the substitution of physical therapy;
c. that Andrew Jones did not receive his medication after 4pm on 20
November 2018 resulting in the sudden cessation of his mood
stabilisation drug and the tramadol for his back pain. Andrew Jones'
Emotionally Unstable Personality Disorder would have resulted in his
experiencing increased levels of back pain above that of the normal
person and enhanced withdrawal symptoms from a lack of opiates.
This lack of prescribed medication was confirmed by toxicology at the
time of his death which showed that Andrew Jones had no opiates or
Quetiapine in his bloodstream;
d. Andrew Jones had been moved from the Residential Support Unit to
the main prison estate where he still continued to believe that he was
under threat;
e. that every positive factor identified on a recent ACCT review had been
removed on his transfer to C Wing resulting in a substantial increase in
risk;
f. that Andrew Jones was segregated and healthcare should have been
summoned no later than 1:30pm on 21 November 2018 to undertake
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
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a safety algorithm and provide an opinion to the prison governor as to
whether or not continued segregation would have a detrimental effect
on Andrew Jones. This would have also detected the
lack of
medication and would have led to an assessment of his mental state.
g. that the lack of a hearing would have given Andrew Jones an
opportunity to have his side of the story heard; and
h. it was the conclusion of the consultant psychiatrist that the
combination of deselection, removal of positive factors, removal of
mood stabilisation drugs, segregation without access to a shower,
telephone or exercise, sudden cessation of opiates resulting in opiate
withdrawal symptoms, no adjudication hearing, lack of distraction
activities created the "perfect storm" and contributed to Andrew Jones
death.
This case demonstrates that there are cases that require a much more
sophisticated approach to achieving a "safe, ordered and decent prison". A
blanket approach to such a variety of cases is inappropriate and does not
achieve this aim in complex cases. Noms tacit acceptance of this method
of investigation indicates that it is missing important information in
achieving a "safe, ordered and decent prison".
(8) Independent Monitoring Board: The Chair of the IMB gave evidence at the
inquest where it became apparent that at times the membership of the IMB
had constituted one person. It was variable as to whether or not there were
IMB members able to attend segregation and there was no indication that
there were sufficient numbers to make any visits for segregation on the wing.
The evidence at the inquest suggested that the membership of the IMB was
insufficient to properly conduct its functions, which include segregation,
which was not considered by the PPO.
(9) General approach to risk within the jail: in this instance the jail removed
almost every single safety feature to protect prisoners and prisoners at risk of
self-harm summarised as follows:
a. Appreciation of risk by the Number One Governor that the RSU
required a deselection protocol which was not completed;
b. Deselection of prisoners from the Residential Support Unit with no
multidisciplinary assessment of past ACCT/self-harm, mental health,
psychology input into the decision along with risk factors for an RSU
prisoner in the wider jail
c. Misapplication by all senior officers and custody managers of wing
segregation rules resulting in mass segregation of prisoners with no
safety algorithm completion, enhanced checks,
involvement of
healthcare et cetera;
d. No risk assessment by the CM prior to transfer or the transferring wing
Senior Officer prior to transfer;
e. No prison records of any discussions regarding transfer or the decision
to transfer a prisoner between wings or of any checks undertaken
prior to transfer
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752
f. No risk assessment by the receiving wing senior officer either on
reception of the prisoner or at any time in the next 36 hours before his
death;
g. Inconsistent medication regimes without explanation;
h. Closure of ACCT forms when either medical treatments were
impossible to deliver or had not been undertaken although the
reduction in analgesics had occurred;
i. Records of post closure interviews been entered in the records when it
was obvious that the risk profile had changed substantially since the
post closure interview took place;
j. No personal officer involvement to ascertain why a prisoner may be
defaulting from the prison regime.
Five years ago I rarely saw any deaths from HMP Garth and those that I
undertook were normally well-managed. This demonstrates a substantial
alteration as to how the jail approaches risk.
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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
22 June 2020. I, 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.
Andrew Jones Father. I have also sent it to Inquest, the Prison Reform Trust and HM
Inspectorate of Prisons 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
Dated 20 April 2020
Signature
for Lancashire & Blackburn with Darwen
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752
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