Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0032, written 10 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Feb 2021 |
|---|---|
| Reference | 2021-0032 |
| Deceased | Jason O’Rourke |
| Coroner | Henrietta Hill QC |
| Coroner area | London Inner (South) |
| Category | State Custody related deaths · Mental Health related deaths · Suicide (from 2015) |
| Organisation named | Oxleas NHS Foundation Trust |
| 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 THIS REPORT IS BEING SENT TO: 1. Governor 2. , HMP Belmarsh , Director General for Prisons, HM Prison Service 1 CORONER I am Henrietta Hill QC, assistant coroner for the coroner area of Inner South London. 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 Jason O’Rourke died on 2nd April 2019 at HMP Belmarsh, aged 34 years. An investigation into his death was commenced. The investigation concluded at the end of the inquest on 21st January 2021. The jury found that the medical cause of Mr O’Rourke’s death was hanging. Their conclusion was that he died by suicide, to which a series of factors possibly contributed, as explained further under section 4 below. 4 CIRCUMSTANCES OF THE DEATH Jason O’Rourke died in his single occupancy cell on House Block 3 in HMP Belmarsh at some point between 7.28 pm on the 1st April 2019 and when he was found at 9.33 am on 2nd April 2019, hanging from the window bars in his cell using a ligature made from a bedsheet. He had clearly been dead for some time. No one had entered Mr O’Rourke’s cell overnight. The roll checks scheduled to take place at 9.00 pm on the night of 1st April 2019 and 6.00 am on the morning of 2nd April 2019 had not been carried out, although it cannot be said that had those checks been done, the outcome would have been any different. Prior to his death Mr O’Rourke had chosen to self-isolate in his cell. The jury found that Mr O’Rourke’s suicide was possibly contributed to be the following factors: (i) (ii) (iii) The serious failure to take further steps with respect to Mr O’Rourke’s mental health after the Primary Care Mental Health Nurse’s attempt to triage him on 8th March 2019; The fact that healthcare staff did not provide sufficient information about Mr O’Rourke’s mental health to prison staff during the month that he was resident on House Block 3; The fact that prison staff on the wing did not have sufficient understanding of Mr O’Rourke’s mental health history and his history of self-harm from (a) information received from healthcare; (b) the information on the Cell Sharing Risk Assessment and (c) information on the OASYS record; and (iv) The fact that the Safety Intervention Meetings in March 2019 were an inadequate way of addressing the issue of self-isolation and risk in relation to Mr O’Rourke. 1 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified. The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “If yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form. It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?” Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing. (2) The nightly roll checks at HMP Belmarsh are due to be carried out by a single member of Operational Support Grade (OSG) staff at 9.00 pm and 6.00 am. Their stated purpose is to check for escape or death among the prisoners. On handing over to the morning staff, the OSG signs paperwork indicating that the roll checks have been completed. There is no robust system by which the prison management audit this process. This means that the prison management can be under the impression that the checks have been carried out, when they have not been, as occurred here. 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, 2 namely by 7th April 2021. 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: (1) The family of Jason O’Rourke (2) The member of OSG staff on duty on the night of 1st/2nd April 2019 (3) Oxleas NHS Foundation Trust. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 10th February 2021
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.
Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Ms Henrietta Hill QC HM Assistant Coroner for Inner South London 1Tennis St London SE1 1YD Dear Ms Hill 6 May 2021 Thank you for your Regulation 28 report of 10 February 2021 following the inquest into the death of Jason O’Rourke at HMP Belmarsh on 2 April 2019. I am grateful to you for granting an extension to the statutory deadline for my response. I know that you will share a copy of this response with the family of Mr O’Rourke and I would like 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. Following evidence heard at the inquest you have raised concerns in relation to the ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh. This is a locally produced document created in line with the Prison Service Instruction (PSI) 07/2015 Early days in Custody. You will be aware that the early days in custody is a period in which risk of self-harm or suicide is heightened and the wellbeing of prisoners in our care is the primary concern of staff throughout the reception and first night process. Following the inquest a review of the form has taken place, and a new version is now in use. This provides clearer guidance to staff on the actions to take should any concerns about a prisoner’s risk of suicide or self-harm be identified, including communicating concerns or previous ACCT history to healthcare colleagues, and documenting decision making so that information is available to wing staff once the prisoner moves onto the wings after their induction period. I attach a copy of the updated immediate needs form for your information. As well as using the immediate needs form to capture information shared by prisoners on how they are feeling, staff working in the reception and first night areas receive specific training in how to recognise risks and triggers for self-harm and suicide and how to support prisoners through the first few days in prison. Beyond the reception and first night process, all staff are trained in how to open an ACCT should they identify evidence of increased risk of self-harm or suicide. You also raised a concern in relation to the nightly roll checks carried out by Operational Support Grade (OSG) staff and the lack of a robust system to ensure that these checks have been completed. The purpose of roll checks is to ensure that prisoners are accounted for, located where they should be, and alive and well. It is mandated that four roll checks are carried out over each 24 hour period and the times of the checks are locally agreed and set out in each prison’s Local Security Strategy (LSS). The duties and expectations of night staff are clearly communicated and staff receive training and shadowing before working alone on the wings overnight. For OSGs these duties include carrying out a roll check at the beginning and end of each shift which must be reported to the control room and signed for. Spot checks by the Night Orderly Officer (NOO) and night visits by an operational manager are in place in establishments, including Belmarsh, to ensure that staff are carrying out their required duties and these provide an opportunity for OSGs to raise any issues or concerns with workload or any unexpected incidents that have occurred during their shift which may prevent them from being able to carry out the roll check or report the roll at the required time. The NOO can be called upon for assistance by OSGs at any time during the night shift. In the light of the concerns that you have expressed, the Governor of HMP Belmarsh is working with the Long Term and High Security Estate (LTHSE) safety team to review the quality assurance processes in place for roll checks. As a first step, a system has been implemented whereby when a night OSG arrives a discipline officer remains on the wing until a full roll check has been completed, recorded and signed for on the wing and reported to the Orderly Officer. Spot checks are in place to ensure that the process is being followed. The LTHSE safety team will be visiting Belmarsh to identify further opportunities for improvement and to test compliance with this new process, and the LSS more generally. I understand that the question of using CCTV for assurance was explored at the inquest. CCTV is deployed in prisons for reasons of safety and security and not for general surveillance or monitoring staff performance. Playback of CCTV coverage is only authorised in certain circumstances, such as where there is reason to believe that safety or security has been compromised, or to assist with a formal investigation. Where there is suspicion that roll checks are not being carried out, CCTV could be used as part of an investigation into those suspicions, but it cannot routinely be monitored as part of the assurance process. Staff are aware that CCTV is in use around the establishment and that their actions may be scrutinised following an incident such as a death in custody. If staff are found to have failed to carry out the required tasks or when there is a question over their performance and ability to manage the wing overnight there will be a thorough investigation to determine what has happened and to ensure that staff who fail to uphold the values of HMPPS by putting prisoner’s safety at risk are held to account through disciplinary procedures. Staff are aware that failure to carry out the duties entrusted to them will result in disciplinary action, and that, depending on the circumstances, the outcome may range from advice and guidance in order to support them to perform better, to dismissal from the service. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised. Yours sincerely Director General for Prisons
See every Prevention of Future Deaths report matching Oxleas NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.