Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0195, written 5 Oct 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Oct 2020 |
|---|---|
| Reference | 2020-0195 |
| Deceased | Wesley Rowlands |
| Coroner | Nicholas Rheinberg |
| Coroner area | Lancashire and Blackburn with Darwen |
| Category | State Custody related deaths |
| 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 REGULATION 28 REPORTTO PREffi THIS REPORT IS BEING SENT TO: The Governor, HMP Garth 1 GORONER I am Nicholas Leslie Rheinberg, assistant coroner for the coroner area of Lancashire and Blackburn with Darwen 2 CORONER'S LEGAL POWERS I make this report under parag raph 7 , Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the coroners (lnvestigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 25th July 2017 an inquest into the death of Wesley Dennis Rowlands was opened. The investigation concluded at the end of the inquest on 2nd october 2020. The conclusion of the inquest was that Wesley Dennis Rowlands died by suicide as a result of ligature hanging. 4 CIRCUMSTANCES OF THE DEATH The deceased ended his life by hanging. According to notes left in his cell at HMP Garth the deceased was filled wlth remorse for harm that he had inflicted on others. The deceased had used a fixed television bracket as a liqature bracket. CORONER'S CONCERNS tr During the course of the inquest the evidence revealed matters giving rise to concern ln my opinion there is a risk that future deaths will occur unless action is taken. ln the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as fottows. - A number of cells at HMP Garth, including the deceased's cell, have television brackets built into the structure of the cellwalls. Although the brackets are now redundant, they remain in place and constitute a gross and obvious ligature point and will continue to do so until removed. h 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 2nd December 2020. l, 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. B COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the family of the deceased and Greater Manchester Healthcare Trust. 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. o Dated Sth ,r] SIGNED Assistant Coroner 2
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 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email:DirectorGeneralPrisons@justice.gov.uk Mr Nicholas Rheinberg Assistant Coroner for Lancashire & Blackburn with Darwen Coroners Court 2 Faraday Court Faraday Drive Preston PR2 9NB 26 November 2020 Dear Mr Rheinberg Thank you for Regulation 28 report of 5 October 2020, addressed to the Governor at HMP Garth, following the recent inquest into the death of Wesley Rowlands at the prison on 14 October 2016. I am responding as Director General of Prisons. I know that you will share a copy of this response with Mr Rowland’s family and I would like first to express my condolences for their loss. Each death in custody is a tragedy and the safety of those in our care is my absolute priority. During the inquest, evidence was given that a number of cells at HMP Garth have television brackets, which are no longer in use, built into the structure of the cells walls, and you have expressed concern that unless removed they will continue to present a potential ligature point. Please be assured that this is an issue that we take very seriously, and arrangements have already been made by our Prison Maintenance Group to review all cells at HMP Garth and to remove the brackets. This work was delayed by the restrictions that we implemented in response to the pandemic, but I can confirm that it will be completed by February 2021. We are seeking also to address any similar risks in other prisons by reviewing all accommodation of the same type, and looking back at reported self-harm incidents, so that we can identify and remove any other unused brackets that offer ligature points. We will also alert Prison Group Directors and Governors to the concerns that you have reported, so that they are aware of the importance of identifying unused brackets and taking prompt action to remove them. Your concerns will inform our decisions relating to future prison capacity and our approach on new prison builds, including house block expansion designs. Our new prison design, which is being used for HMP Five Wells, the new prison at Glen Parva and four other new prisons, includes cells that will be finished to a ‘safer cell’ standard, meaning that ligature points have been designed out as far as possible and other design and construction measures have been taken to minimise the instances of self-harm. A number of observation cells have also been placed in each of the houseblocks and Care & Separation Units (CASU) so that prisoners who have been identified as at immediate risk of self-harm can be monitored and managed appropriately. These cells will be used alongside the support provided to a prisoner from staff, healthcare providers and other partners. In addition, cells have been designed to reduce ‘blind spots’, enabling staff to check and confirm the wellbeing of prisoners more effectively. Thank you again for bringing these matters of concern to my attention. We will ensure learning from this tragic incident is taken forward. Yours sincerely, Director General for Prisons
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