Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0189, written 2 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jun 2021 |
|---|---|
| Reference | 2021-0189 |
| Deceased | Mark Culverhouse |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Rt Hon Robert Buckland QC Lord Chancellor Ministry of Justice 1 CORONER I am Tom OSBORNE, Senior Coroner for the area of Milton Keynes 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 On 30/04/2019 I commenced an investigation into the death of Mark Samuel CULVERHOUSE aged 29. The investigation concluded at the end of the inquest on 21 May 2021. The conclusion of the inquest was: I a Hypoxic brain injury and pneumonia I b Cardiac arrest (resuscitated) I c Ligature compression of the neck The jury concluded by a majority of 9-2 that he had died from suicide they also concluded that he had been unlawfully detained and this had contributed to his death and that the decision to take him to segregation on the 23rd April 2019 had contributed to his death It was here where the first serious concerns regarding his mental health 4 CIRCUMSTANCES OF THE DEATH as found by the jury On 17th April 2019, Mr Mark Samuel Culverhouse was involved in an incident where police negotiators in attendance found Mark to be presenting as a person in crisis; he had a noose around his neck and was actively self-harming. After several hours, Mark is taken to Northampton Criminal Justice Centre where he was booked and assessed by a doctor. were raised. Mark is seen by two doctors who seem him fit to be detained and fit to be questioned. On the morning of 18th April, Mark was transferred to Northampton Magistrates Court. On arrival Mark’s behaviour was presenting as erratic and he was head banging. A mental health assessment was requested as several staff were concerned about his behaviour. Whilst being seen by the mental health team he self-harms by head butting the wall and collapses. As a result he was sent to Northampton General Hospital. At both locations, Mark indicated if he was to return to prison he would take his own life. Whilst in hospital, the probation service recalls Mark’s license due to the addition charges from 17th April. A police officer attends hospital to serve the recall and Mark is taken to HMP Woodhill once discharged. Mark is still presenting as a person in crisis when he leaves the hospital. On arrival at HMP Woodhill, Mark is placed on an ACCT under constant observation. Mark is seen by a doctor and later that evening his observations are reduced to 3 times an hour by the duty governor. On 19th April, Mark smashes his TV and observation panel and is taken to the segregation unit. Not long after going into segregation, Mark was found unresponsive. He is taken to Milton Keynes Hospital where he refuses to receive treatment from both medical and mental health teams. He is returned to prison and placed on constant observations to keep him safe. On 20th April, a mental health nurse referred Mark for a mental health assessment which was It was considered Mark had no unmet mental health carried out on the morning of 23rd April. needs and that he was not suffering from a mental illness. A review of his ACCT reduced the level of his observations. Mark was accepted onto the mental health case load. At 11am on 23rd April the Offender Management Team calculated that Mark is potentially due for immediate release. This was not communicated to Mark. Validation checks later confirm Mark should be released but he was never made aware of this. At 1355 Mark had an altercation with another prisoner, he is restrained and taken to the segregation unit for a second time. The primary care nurse was unable to sign the segregation algorithm due to Mark’s presentation and requested input from the mental health team. Mark was observed twice in his cell, the first he was seen with movement in his leg and the second time he was heard singing; in both events he was under a sheet, his body obscured from view and thus was insufficiently observed. A mental health nurse arrives and sees no movement. She asks for the door to be open. At 1449 prison staff enter his cell and Mark is discovered with a ligature around his neck. He is resuscitated and taken to Milton Keynes University Hospital where he dies on 24th April 2019 at 1439. It is clear he was presenting as a person in crisis again. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: During the course of the inquest into the death of Mark Culverhouse it became apparent, and indeed was accepted that his detention at HMP Woodhill from the 18th of April 2019 until the 23rd of April 2019 was unlawful. He had been recalled under the terms of his license having been released from Peterborough prison on the 12th of April 2019. The calculation of his release date was not conducted by the offender management unit at the prison until the 23rd of April 2019, after the extended Easter bank holiday. I was told that there was no process in place whereby a prisoner’s release is calculated until such time as they come back into custody. The prison and probation ombudsman brought this matter to the attention of the prison service recommending that the release date calculation should take place within one working day of the prisoner arriving in prison. I cannot see how that can be acceptable particularly where, in Mr Culverhouse’s case, it would have made no difference because of the bank holiday. I consider that there was a clear link between his unlawful detention and his eventual death on the 24th of April 2019 and, in order to prevent similar deaths in the future, I believe an urgent review is required and the system changed to ensure that the calculation of the release date is made prior to the decision to recall being taken. This will avoid the possibility of anyone being unlawfully imprisoned in this country under similar circumstances. 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, namely by 19 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 and to the following Interested Persons Family HMP Woodhill Government Legal GeoAmey CNWL Northamptonshire Police 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 Tom OSBORNE Senior Coroner for Milton Keynes Dated: 02 June 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 29 July 2021 Mr Thomas Osborne HM Senior Coroner for Milton Keynes Unit 56, Innovation Centre 1 Saxon Gate East Milton Keynes Buckinghamshire MK9 3EJ Dear Mr Osborne, Thank you for your Regulation 28 report of 2 June 2021 following the inquest into the death of Mark Culverhouse at HMP Woodhill on 24 April 2019. I know that you will share a copy of this response with the family of Mr Culverhouse 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 a concern in relation to how offenders’ sentences are calculated and recommended that an urgent review take place to change the system to ensure that calculation of release dates is made prior to a decision to recall. After careful consideration, we must advise that we do not consider it possible to comply with the recommendation for the following reasons: 1. 2. 3. The calculation of release dates is complex and must only be undertaken by staff who are trained in the subject. Those staff are located in the Prison Service and only operate during normal office hours between Monday and Friday. Calculations carried out by untrained staff would present the risk of incorrect information being communicated to the prisoner and possibility of a release in error, hence potentially putting the public at risk. Until the point the licence revocation document is issued, it is not possible to calculate the balance of the sentence that remains to be served. Therefore, until the point of recall, it is not possible to establish whether the application of any balance of uncredited remand time would result in the immediate release of the prisoner or not. The application of unspent remand time works differently depending on the type of recall (a fixed term recall or a standard recall) that is issued. In a fixed term recall one day of unspent remand time is applied to the sentence for every day that is 4. 5. physically served in custody. In a standard recall the whole balance of unspent remand time can be applied to the sentence. Confirmation of the type of recall cannot be confirmed at the point the revocation order is issued because it may be subject to change. For example, an offender recalled on a fixed term basis, who remains unlawfully at large for a period of time, may have their recall changed to a standard recall when the details of their behaviour during the period they are unlawfully at large and any further offending behaviour during that period have been taken into account. As the application of remand time differs between the two types of recall, it is not possible to provide an accurate calculation of the re-release date until the recall type has been confirmed. We would be concerned about the possible detrimental effect to a prisoner’s wellbeing if an inaccurate release date was communicated on return to prison custody and similarly concerned about an increased risk of a prisoner being released in error, which could lead to a heightened risk to public protection. In this particular case, following the recommendation made by the Prisons and Probation Ombudsman (PPO), work was carried out to add an alert flag to the National Offender Management Information System (NOMIS) to warn staff when there is unspent remand time on a prisoner’s record which may cause a reduction in the time a prisoner should spend in custody or which may give rise to an immediate release. Sentence calculation is carried out as a priority in these circumstances. In response to your concerns, the sentence calculation policy team will be issuing further communication to all staff about the importance of using the alerts on NOMIS to flag prisoners with unspent remand time in order to reduce the risk of prisoners being detained longer than required and to confirm release dates to recalled prisoners as soon as possible. Thank you again for bringing your concerns to my attention. I hope that this response provides assurance that action is being taken to mitigate the risk of prisoners spending more time in custody than is legally required whilst also balancing the complexities of sentence calculation, types of recalls, and public safety. Yours sincerely Director General for Prisons
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