Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0245, written 16 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jul 2021 |
|---|---|
| Reference | 2021-0245 |
| Deceased | Joanna Daly |
| Coroner | John Hobson |
| Coroner area | West Yorkshire (Eastern) |
| Category | Alcohol, drug and medication related deaths · 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Ministry of Justice. 1 CORONER I am John Hobson, an Assistant Coroner for the Coroner area of West Yorkshire (Eastern). 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 4th June 2019, an investigation was commenced into the death of Miss Joanna Daly, aged 35. The investigation concluded at the end of the Inquest held before a jury on 6 July 2021. The jury recorded that the medical cause of death was: 1 a Ventricular arrhythmia leading to cardiac arrest 1 b Use of illicit cocaine A narrative conclusion was recorded by the jury as follows: 'Joanna's death was drug related. The roll checks carried out by prison staff were adequate. The healthcare checks were not carried out adequately and this could have been a contributing factor to her death'. 4 CIRCUMSTANCES OF THE DEATH On 1 June 2018 Miss Joanna Daly was admitted to HMP New Hall following a breach of licence conditions following previous sentencing. She had been released from HMP New Hall on 20 May 2018. Upon arrival, it was noted that she was experiencing withdrawal from drugs. Following nursing and medical assessment, she was taken to the First Night Centre. As with all first night prisoners, night checks were undertaken by healthcare staff. Roll checks were conducted by prison staff. On the morning of 2 June 2019, Miss Daly was found unresponsive in her cell and her death was confirmed. 5 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. 1 The matter of concern is as follows: - During the course of the Inquest, the matter of checks undertaken by healthcare staff on prisoners resident for their first night in the prison's First Night Centre was heard in evidence. The jury found that no guidance as to how such checks were to be conducted had been provided to the staff undertaking the checks, and that it was possible that this contributed to Joanna's death. Since Joanna's death, changes within HMP New Hall have been undertaken whereby welfare checks undertaken at the First Night Centre are now completed by prison staff. The new arrangements have been in place since October 2020. Whilst evidence was provided of the key times at which such checks are undertaken, it became apparent that there was no specific guidance provided to prison staff to explain what was required to be undertaken during a welfare check. The particular vulnerability of prisoners resident on the First Night Centre is the reason for such checks. I am concerned about the absence of any specific guidance, in view of the findings of the jury in relation to the night checks that were previously undertaken by the healthcare staff at the time of Joanna's death. This could impact upon the quality of the welfare checks that are now undertaken by the prison staff, in the context of the First Night Centre where prisoners may be particularly vulnerable. I am under a duty to report this matter upon consideration of the evidence as provided to the court. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 22 nd September 2021. I, John Hobson, 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 family and Practice Plus Group who were Interested Parties at the Inquest. 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 Friday 16th July 2021 Signed ........~ ............................. 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 John Hobson H.M Assistant Coroner for West Yorkshire Station Approach Woking GU22 7AP 22 September 2021 Dear Mr Hobson, Thank you for your Regulation 28 Report dated 16 July 2021 addressed to the Ministry of Justice following the inquest into the death of Joanna Daly at HMP New Hall on 02 June 2019. I am responding as Director General for Prisons. I know that you will share a copy of this response with Ms Daly’s family, and I would like to first express my sincere condolences for their loss, every death in custody is a tragedy. You have expressed concern that there is no specific guidance provided to prison staff regarding what is required to be undertaken during a welfare check. Since Ms Daly’s death, HMP New Hall has introduced new processes to improve the quality of welfare checks. In July 2021, a notice to staff was issued covering First Night Centre welfare checks during night state – most easily described to those not familiar with the term as the time during the night whereby all people in custody are residing within their cells and no activity occurs out of cell. The notice revised previous instructions and clarified that staff must now obtain a response from a resident in the First Night Centre. The notice details the times welfare checks should take place, the purpose of the welfare check and what is required from a welfare check. It also reminds staff to create a record summary for all those in custody during the night state on the National Offender Management Information System (an electronic record of all individuals in custody). These changes have also been included in HMP New Hall’s local operating instructions, which were published in July 2021. Thank you again for bringing your concern to my attention. I trust that this response provides assurance that this is an issue that we take seriously, and that appropriate action has been taken. Yours sincerely, Director General for Prisons
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