Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0179, written 25 May 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 May 2021 |
|---|---|
| Reference | 2021-0179 |
| Deceased | James Devenny |
| Coroner | Ian Brownhill |
| Coroner area | Mid Kent and Medway |
| Category | State Custody related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Mid Kent and Medway Coroners Cantium House 2nd Floor Maidstone Kent ME14 1XD REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Governing Governor, HMP Elmley 2. , D i r e c t o r G e n e r a l , P r i s o n s 1 CORONER I am Ian Brownhill, assistant coroner, for the coroner area of Mid Kent and Medway 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 James Devenny died on 2 September 2019 at HMP Elmley, aged 34 years. An investigation into his death was commenced. The investigation concluded at the end of the inquest on 18 May 2021. The jury found that the medical cause of Mr Devenny’s death was hanging. Their conclusion was that he died of an accidental death and there was a failure to open an ACCT document which caused or contributed to his death. The jury also found a series of factors possibly contributed, as explained further under section 4 below. 4 CIRCUMSTANCES OF THE DEATH James Devenny died in his single occupancy cell on House Block 2 in HMP Elmley at some point between 1433 and 1558 on 2 September 2019 when he was found, hanging from a light fitting in his cell using a ligature made from a bedsheet. Prior to his death Mr Devenny had been isolated in his cell due to a concern that he posed a risk of violence. The jury found that Mr Devenny’s Death was possibly contributed to by the following factors: (1) Staff on houseblock 2 at HMP Elmley were not aware of information as to his history of self-harm which occurred before he arrived there. (2) Following the decision to keep Mr Devenny separated from other prisoners, there was not an assessment by a medical professional as to whether he was fit to be separated. (3) The response of the mental health in reach team to referrals in respect of Mr Devenny was not appropriate. In addition, the jury noted in their narrative that: (1) We feel that lack of access to a phone in cells, to contact support services was inadequate 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) In the absence of telephones which are installed directly into the cell, there is no direct means for a prisoner to contact the Samaritans. In the event that a prisoner does not have access to a telephone they are reliant on staff to convey them to a telephone so they may call. There is a particular difficulty in respect of prisoners who are deemed to pose a risk of violence and who may not be able to immediately access a telephone, a listener or a member of Chaplaincy. (2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed save that they will be informed if a prisoner arrives with an open ACCT. Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm. 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 20 July 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 The family of James Devenny Oxleas NHS Foundation Trust IC24 The legal representatives of the above. In addition, I have sent this to: , Her Majesty’s Inspector of Prisons , Chair of the Independent Panel on Deaths in Custody 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 Signature: Ian Brownhill Assistant Coroner Mid Kent and Medway 25 May 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 Mr Ian Brownhill Assistant Coroner Mid Kent and Medway Coroners Cantium House 2nd Floor Maidstone Kent ME14 1XD 20 September 2021 Dear Mr Brownhill, Thank you for your Regulation 28 report of 25 May 2021 following the inquest into the death of James Devenny at HMP Elmley on 2 September 2019. I am informed there was an administrative error on our part for which I apologise and as such, 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 Devenny 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 about individuals’ direct access to the Samaritans phone line, and also that Prison Officers are not routinely briefed about individuals’ previous self-harm in custody. Thank you for bringing your concerns to my attention. At the time of Mr Devenny’s death, in-cell telephony had only recently been introduced at HMP Elmley, and there were initially some supply issues which meant that not all cells were equipped with the necessary handsets. These have now been resolved, and with the exception of those in the Care and Separation Unit (CSU) and Healthcare in-patients, all those in custody at HMP Elmley now have in-cell phones. All people in custody across the prison estate are able to call Samaritans without charge using a pin number given out on induction and widely circulated around the prison. In the event that in-cell telephony is unavailable, individuals can also request the dedicated Samaritans phones that are held in each wing office and are taken to people in their cells. These phones have been updated, and the handsets are now bright green, as a visual association with the colours used by the Samaritans and to make them more visible to staff so that they can be quickly identified and provided once requested. These phones are programmed with only the Samaritans phone number and staff check them regularly to ensure that they are in full working order. Your second concern is that prison officers are not routinely briefed about people who have previously significantly self-harmed in custody. While a knowledge of previous self-harm can be useful, and this information will be noted if it is available either on “National Offender Management Information System” the system used for information about those in custody, or disclosed by the individual in question, previous incidents will not always be relevant in identifying current risks and triggers. As HMP Elmley is a busy local prison with a high turnover of people in their care, there is a focus on recognising risk and triggers for self- harm and suicide and being alert to any changes in an individual which may indicate an increase in risk. You will recall that evidence was given at the inquest about the updated version of Assessment Care in Custody and Teamwork version 6 (ACCT v6), which was due to be rolled out shortly after the inquest. I am pleased to confirm that ACCT v6 went live across the male estate in July 2021. Along with updates and improvements made to the ACCT document there is also an increased emphasis placed on up-skilling staff in relation to risk identification, and revised training modules and awareness materials have been made available to all staff at the prison. The prison also now operates the Key Worker scheme, whereby all people in custody have a dedicated Key Worker who meets with them on a weekly basis. The intention of Key Work is to enable better relationships between staff and people in prison, and to support those in custody to settle into prison life. Key Workers are expected to be aware of an individual’s history and to work with them to help and support them with any issues. As part of this role key workers review National Offender Management Information System (NOMIS) case notes and look at any previous issues or risks, including self-harm. They are therefore well placed to recognise any changes in the level of an individual’s risk of self-harm or suicide and to be aware of any potential trigger dates which may indicate that an ACCT should be opened to provide increased support. An updated safety diagnostic tool which provides information about individuals is available to all staff. This includes information on violence and self-harm, and other relevant information drawn from NOMIS. The tool makes it easier to access all relevant risk information in one place and is routinely used by safer custody staff who flag any new receptions and any individuals they are concerned about to wing staff and other relevant departments within the prison. Thank you again for bringing your concerns to my attention. I trust that this response provides you with assurance that action has been taken to address your concerns. Yours sincerely, Director General for Prisons
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