Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0217, written 23 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 | 23 Jun 2021 |
|---|---|
| Reference | 2021-0217 |
| Deceased | Wayne Boughen |
| Coroner | James Hargan |
| Coroner area | West Yorkshire (Eastern) |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Governor, HMP Leeds, c/o , Government Legal Department 1 CORONER I am James Hargan, Assistant Coroner, for the Coroner area of West Yorkshire (E). 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 21st November 2018, Senior Coroner, Kevin McLoughlin commenced an investigation into the death of Wayne Boughen, aged 40. The investigation concluded at the end of the Inquest on Thursday 3rd June 2021. The conclusion of the Inquest was that Wayne Boughen deliberately suspended himself with a ligature around his neck, but the jury were unable to determine his intention in doing so. The medical cause of death was 1a. hypoxic-ischaemic encephalopathy, 1b. hanging. 4 CIRCUMSTANCES OF THE DEATH as recorded by the jury; Wayne Boughen was detained in HMP Leeds at the time of his hanging. He was found suspended from a ligature in cell D2-42 at 00:42 hours on 16th November 2018 and died in Leeds General Infirmary on 17th November 2018. Wayne deliberately suspended himself from a ligature and no one else was involved in his death. As to Wayne’s intentions the evidence is inconclusive. The wider circumstances of Wayne’s death are as follows: 1. Recent (within the 5 weeks leading up to his death) incidents of self-harm, threats of suicide and a claimed suicide attempt. 2. A missed visit from his mother in the days before his death. The reasons for the cancellation of this visit were unclear. Wayne had stated the importance of this relationship to his well-being. 3. The psychiatric evaluation planned for 14th did not take place. No reason has been established. 4. There was an open ACCT requiring among other things (at the time of the hanging) hourly irregular observations. 5. Prison officers differed in their interpretation of ‘hourly irregular observations’ eg whether that required a maximum of 60 minutes between observations. 6. Wayne was in a standard cell. 7. There were no cells in HMP Leeds meeting the national guidelines for safer cells. 8. Family members and fellow prisoners had raised concerns about Wayne’s mental health in the weeks before his death. 5 CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern. In 1 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 MATTERS OF CONCERN are as follows. – 1. At the time of Wayne Boughen’s death, HMP Leeds did not have any cells which were certified safer cells (anti-ligature cells) in accordance with national standards. 2. HMP Leeds still does not have any such certified safer cells. 3. HMP Leeds has a small number of cells which have an increased level of safety as compared with the majority of cells within the prison, but even they do not comply with the certified safer cell standard. In an ordinary cell, Wayne Boughen was able to suspend himself using a ligature fashioned from a prison issue jumper. 4. 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 Wednesday 18th August 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. 2. 3. 4. 5. , Practice Plus Group , Daughter , Brother , Uncle , Ex-partner I have also sent it to the Lord Chancellor Secretary of State for Justice, The Rt Hon Robert Buckland QC MP 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 Signed: MR JAMES HARGAN Assistant Coroner West Yorkshire (E) Dated: 23th June 2021 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.
Director General Prisons
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London SW1H 9AJ
Mr James Hargan
Assistant Coroner for West Yorkshire (E)
71 Northgate
Wakefield
West Yorkshire
WF1 3BS
13 August 2021
Dear Mr Hargan
Thank you for Regulation 28 report of 23 June 2021, addressed to the Governor of HMP
Leeds, following the recent inquest into the death of Wayne Boughen at the prison on 17
November 2018. I am responding as Director General for Prisons.
I know that you will share a copy of this response with Mr Boughen’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 case is my absolute priority.
During the inquest, evidence was given that at the time of Mr Boughen’s death HMP Leeds
did not have any certified safer cells which met the national published standard and that this
position remained unchanged. You were concerned that although the prison has a small
number of cells which have an increased level of safety, these still did not comply with the
certified standard. You note that Mr Boughen was located in an ordinary cell when he died.
I fully appreciate your concerns and would like to reassure you that we are committed to
ensuring that prisoners in our care, particularly those who are considered to be at a risk of
suicide or self-harm, are located in the safest environment possible. We recognise that cell
safety is an important part of managing prisoners at risk, and wherever possible new builds
and major refurbishment projects are delivered to the published safer cell specification.
However we also know that placing someone who has been identified as being at risk in a
safer cell that is fully compliant with the standard does not fully eliminate that risk. We
therefore believe that whilst safer cells can be of assistance, they are not sufficient on their
own to protect prisoners.
Many older establishments, including HMP Leeds, are built in a way that it makes it
impossible to refurbish most cells in a way that fully meets every aspect of the safer cell
specification. For this reason there is no requirement in our policy for prisons to have, or to
use, safer cells. Nonetheless the Governor of HMP Leeds is committed to improving the
safety of the available accommodation where possible, and will continue to work with Amey,
the maintenance contractor, to identify opportunities for further work to reduce the
availability of ligature points in cells.
We believe that the best way to protect prisoners at risk is through the individualised, multi-
disciplinary case management provided by the Assessment, Care in Custody Teamwork
(ACCT) process https://www.gov.uk/government/publications/managing-prisoner-safety-in-
custody-psi-642011
Since the inquest a revised version of the ACCT has been fully introduced across the male
estate, including at HMP Leeds. All staff at the prison have received awareness training
specific to their roles and responsibilities and to highlight the key changes to the
procedures. Some of the improvements made to the ACCT document are designed to lead
to a better standard of record keeping and to ensure that key risk information is highlighted
more clearly on a form that is updated throughout the process and encourages more
meaningful interaction with prisoners at risk. An individualised assessment, considering
risks, triggers and protective factors, is completed and used to produce an appropriate care
plan setting out the support being offered to the individual concerned. This includes
consideration of the prisoner’s location, and the option to remove or restrict access to items
that may be used as ligatures and/or the provision of alternative clothing. If risk is
considered to be very high, levels of observation can be increased, and for those in acute
crisis, constant supervision can be deployed. Implementation of the new version of ACCT at
HMP Leeds is being monitored carefully by the Governor and safety team, with regular
feedback to managers and individual staff highlighting any need for improvement and good
practice where appropriate. I am confident that these measures will improve the operation
of the ACCT process at HMP Leeds.
Thank you again for bringing these matters of concern to my attention. I hope this provides
assurance that whilst the situation with regard to the availability of safer cells remains
unchanged, the measures that have been taken to improve the ACCT system, and to
ensure that the revised version is fully implemented at HMP Leeds, will ensure that
prisoners identified as being at risk of self-harm and suicide are safely managed.
Yours sincerely
Director General for Prisons
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