Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0256, written 28 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 | 28 Jul 2021 |
|---|---|
| Reference | 2021-0256 |
| Deceased | Carl Walters |
| Coroner | Nicholas Rheinberg |
| Coroner area | Exeter and Greater Devon |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Governor, HMP Exeter CORONER 1 I am Nicholas Leslie Rheinberg, assistant coroner for the coroner area of Exeter and Greater Devon 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 14th July 2021 I commenced an inquest into the death of Carl Lee Walters aged 34. The investigation concluded at the end of the inquest on 21st July 2021. The conclusion of the inquest was that Mr Walters died as a result of intraperitoneal haemorrhage due to a ruptured splenic pseudoaneurysm of undetermined aetiology, the evidence not revealing whether this was naturally occurring or trauma related and if the latter whether the trauma arose out of an accidental blunt force impact or an assault. 4 5 CIRCUMSTANCES OF THE DEATH Mr Walters died suddenly and unexpectedly in his cell. The cause of his death was a ruptured splenic pseudoaneurysm which was most likely to have been trauma related. Although there was no evidence to the effect that Mr Walters had been injured whilst he was in prison the possibility nevertheless existed. As such it was very important that prison CCTV footage should be examined. Further, Mr Walters’ cellmate alleged that he had pressed the emergency cell bell on numerous occasions. However, despite the provisions of Chapter 12 of PSI 64/2011 CCTV images had not been preserved and only limited cell bell records had been kept. 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 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. – The failure to preserve key evidence meant that the inquest could not be as full as it would otherwise have been. If key evidence is not preserved there is an ongoing risk that dangerous conditions or circumstances go undiscovered raising the prospect that appropriate steps to avoid a similar tragedy are overlooked. 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 1 You are under a duty to respond to this report within 56 days of the date of this report, namely 24th September 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 namely the family of the deceased and the health provider 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 Dated 28th July 2021 SIGNED N.L.Rheinberg Nicholas Rheinberg Assistant Coroner 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 06 October 2021 Mr Nicholas Leslie Rheinberg Assistant Coroner Room 226 County Hall Topsham Road Exeter Devon EX2 4QD Dear Mr Rheinberg, Thank you for your Regulation 28 report of 28 July 2021 following the inquest into the death of Carl Lee Walters at HMP Exeter on 30 March 2019. 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 Walters 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 the inquest, you have raised a concern in relation to the failure to preserve key evidence which could mean that dangerous conditions or circumstances go undiscovered. You point out that this raises the prospect that appropriate steps to avoid a similar tragedy are overlooked. I am grateful to you for bringing your concern to my attention. As a consequence of Mr Walters’ death and the discovery of HMP Exeter’s deficiencies with regard to the preservation of key evidence, new measures and processes have been put in place to prevent similar circumstances in the future. In particular, HMP Exeter have created a local operating policy for deaths in custody, which contains a list of essential documents that must be retained and the required actions. Included within the list is the collation of relevant cell bell records, CCTV and Body Worn Video Camera footage of any incident. Also, since Mr Walters’ death a new CCTV system has been installed which provides a more reliable source of footage. In addition to the above, all deaths in custody at HMP Exeter are subject to a quick time learning review conducted by the Head of Safety and Regional Groups Safety Lead. This occurs within 72 hours of any apparent self-inflicted death taking place and as a result requires all pertinent information, including CCTV footage and cell bell records, to be made available and reviewed. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised. Yours sincerely Director General for Prisons
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