Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0035, written 11 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 | 11 Feb 2021 |
|---|---|
| Reference | 2021-0035 |
| Deceased | Michael Dobson |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | State Custody related deaths · Mental Health related deaths · Suicide (from 2015) |
| 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: 11 February 2021 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: EE oir ector HMP Dovegate, Marchington, Uttoxeter, Staffordshire, ST14 8XR 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. http:/Avww. legislation .gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/201 3/1629/part/7/made INVESTIGATION and INQUEST On 26 November 2019 | commenced an investigation into the death of Michael Richie DOBSON (‘Mike’). The investigation concluded at the end of the inquest on 9 February 2021. The conclusion of the inquest was suicide with the cause of death being hanging. CIRCUMSTANCES OF THE DEATH Mike applied a ligature to himself using a piece of linen/sheet through a hole in the ceiling and hanged himself. This hanging occurred on 24.11.2019 at an approximate time between 19.00 and 19.25. Death was pronounced at Queen’s Hospital Bruton on 22.25 on 24.11.2019. Probably causative factors: Mike had long standing poor mental health issues. There were also issues around illicit drug use. Mike had fractured family relationships. Mike had difficulties in establishing and engaging with relationships and the support offered to him. Possibly causative factors: A lack of central base of information accessible to all relevant staff with useable information. 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk 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. — The hanging incident occurred after prison lockdown. Shortly prior to this the electricity supply for the sockets in the cell had tripped. Mike had used his cell bell to call a prison officer and he was told it would be sorted out but probably not until the next day. The inquest also heard that in some cases (not Mike's) that cell lights will trip and this tends to take out four cells. It is also possible that other damage may be caused to cells. | am aware that there are very limited staff and security concerns following lockdown. If however prisoners become aware that remedial action may not take place until the following day this does provide a potential (either deliberate or accidental) for prisoners to harm themselves. | wonder if it is possible for some form of basic maintenance to be available during lockdown hours. If this concern appears more to be a national one rather than a local one then please feel free to pass it on to whoever it is appropriate to deal with it. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. Otherwise you should explain why no action is proposed. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8 April 2021. Your response must contain details of action taken or proposed action to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons HCB Solicitors — representing the family, DWF Law — representing Serco, Capsticks — representing Midlands Partnership Foundation Trust and Hill Dickinson Solicitors - representing Practice Plus. | have also sent it to Prison and Probations Ombudsman and the Independent Monitoring Board. | 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. 11 February 2021 ha A Andrew 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.
PU Telephone: | Facsimile +44 (0) 1283 820066 | www.serco.com Serco Home Affairs, HMP Dovegate, Uttoxeter, ST14 8XR, United Kingdom 8th April 2021 To Whom it May Concern, In response to the Regulation 28 letter dated 11th February 2021, (case ID; ), regarding the investigation and inquest in the death of Mr Michael Richie Dobson, HMP Dovegate’s Safer Custody department have ensured that there is a system in place to remedy electricity faults within cells during out of hours facilities times. There is an on-call facilities maintenance officer who can be contacted at any time of day to come into the Prison when there is a fault that cannot be rectified internally by the Duty Manager. The Duty Manager team have been made aware that electricity should not be left inactive for any period of time and that it is their responsibility to contact the facilities ‘on call officer’ to attend the prison to rectify any issues. Whilst the death of Mr Michael Richie Dobson is not an example of electricity being left inactive, HMP Dovegate’s management team recognise that inadequate basic supplies in cells could result in a Prisoner harming themselves and could cause unnecessary emotional distress. The Safer Custody team at HMP Dovegate would like to offer assurances that this issue has been rectified. Yours sincerely, Serco Home Affairs, a division of Serco Limited. A company registered in England and Wales No. 02733334 Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire, RG27 9UY, United Kingdom.
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