Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0281, written 18 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 | 18 May 2021 |
|---|---|
| Reference | 2021-0281 |
| Deceased | Todd Salter |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | Suicide (from 2015) · Mental Health related deaths · Other related deaths · Alcohol, drug and medication 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.
MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) CORONER'S COURT AND OFFICE CROWN COURT COLLEGE ROAD DONCASTER DN1 3HS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The National Probation Service, FAQ General 1. CORONER , Director I am Ms N J Mundy for South Yorkshire East 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 4 October 2019 I commenced an investigation into the death of Todd James Salter. The investigation concluded at the end of the inquest . The conclusion of the inquest was: Suicide 1 a Suspension by ligature 4. CIRCUMSTANCES OF THE DEATH Mr Salter was released from prison on licence in July 2019. Upon his release there was confusion regarding which organisation had responsibility to assist him with housing leading to him residing with his family. This had a deleterious effect on Mr Salter's mental health as independent living was a key element of him being able to re-establish contact with his daughters. As time progressed Mr Salter's struggles with life increased, the spice habit he had in prison combined with life challenges led to him taking illicit drugs. Although Mr Salter wished to overcome his drug habit he and his family struggled to obtain support needed from the various agencies. Of note was that the Probation officer who had been assigned to Mr Salter stated in evidence that she did not know that an option available to her was to contact ASPIRE Drug and Alcohol Service for Doncaster. She further stated in evidence that she did not know that they could have referred Mr Salter for an assessment, could have sought advice from a Consultant psychiatrist and could have liaised with mental health services together with Mr Salter's mother. These were all crucial elements in providing Mr Salter with the support he clearly needed. As it was, the Probation officer was exploring options to have Mr Salter recalled but communication with Mr Salter as to her intentions in this regard were far from clear. By the 30th September 2019 he was at crisis point, left his mother's address, made his way to Doncaster police station where at some time between 02:41 a.m. and 07:15 a.m. on the 1st October 2019 Mr Salter hanged himself outside the police station. 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 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) The lack of knowledge of the Probation officer as to the services she could contact to obtain necessary mental health assessments. This would appear at the very least to suggest this gap in knowledge may be due to inadequate training. (2) Mr Salter being driven to desperate measures of committing criminal acts in an effort to be arrested or recalled in order to secure treatment and support; this appeared to be the way matters were moving forward without engaging with appropriate mental health services. (3) Generally poor engagement and collaborative working with both agencies and family alike. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Probation Service have the power to take such action. 7. YOUR RESPONSE , National You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th 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: , Messrs Browne Jacobson and Government Legal Department. 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. undy LLB (Ho s) Senior Coroner for South Yorkshire East District
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.
Ms N J Mundy
HM Senior Coroner South Yorkshire East
District
Director General of Probation and Wales
HM Prison and Probation Service
3rd Floor Churchill House
Churchill Way
Cardiff CF10 2HH
29 July 2021
Dear / Annwyl Ms Mundy,
Inquest into the death of Mr Todd James Salter
Thank you for your Regulation 28 Report, issued following the Inquest into the death of Mr. Salter.
I am replying as the Director General of Probation and Wales, part of Her Majesty’s Prison &
Probation Service (HMPPS).
I know that you will share a copy of this response with the family and I would first like to express my
sincere condolences for their loss. Every death in such circumstances is a tragedy and the
implementation of learning from this is my absolute priority.
I set out below the response to the matters you have raised giving rise to concern.
(1) The lack of knowledge of the Probation Officer as to the services she could contact to obtain
necessary mental health assessments. This would appear at the very least to suggest this gap
in knowledge may be due to inadequate training.
(2) Mr Salter being driven to desperate measures of committing criminal acts in an effort to be
arrested or recalled in order to secure treatment and support; this appears to be the way
matters were moving forward without engaging with appropriate mental health services.
First, please be assured that the identified lack of knowledge and training gaps have been and
continue to be dealt with at an individual level with the specific member of staff concerned in
accordance with organisational policy and procedure. In addition, the Regional Psychologist has
delivered briefing sessions to staff on suicide prevention and processes have been updated in
EQUIP, the probation service process management data base.
More widely, and prior to this death, it was known that there was a much higher prevalence of mental
health problems with those in society who came into contact with the criminal justice system and it
was acknowledged that they often encountered problems accessing mental health services in a way
that catered for their multiple and complex needs.
In September 2019, because of the complexity of, and interdependences between the health and
justice systems, the Probation Service published a Health & Social Care Strategy 2019 – 2022. This
included the following three commitments:
•
Improve the health and well being of people under probation supervision, and contribute to
reducing health inequalities within the criminal justice system
• Reduce re-offending by addressing health and social care related drivers of offending
behaviour to reduce victims of crime
• Support the development of robust pathways into services for people under probation
supervision, including improving continuity of care between the custodial and community
setting
To support the delivery of these commitments the following actions have been taken:
A Reducing Re-Offending Directorate was established within Her Majesty’s Prison & Probation
Service and the Executive Director has responsibility for the collaborative working with health partners
to deliver improved mental health and substance misuse outcomes. This Directorate works across
government and with the wider public and voluntary sector to reduce reoffending, primarily through
improving accommodation, employment and substance misuse outcomes for those in the criminal
justice system, particularly when leaving prison.
The Probation Service, as part of its unification programme, developed a new Target Operating Model
(published in February 2021) which includes the implementation of the commitments set out in the
Health & Social Care Strategy to enable the further development of collaborative working at a local
level.
(3) Generally poor engagement and collaborative working with both agencies and family alike.
The development of the Health & Social Care Strategy, the creation of a Directorate with specific
responsibility for reducing re-offending and the implementation of the new Target Operating Model will
enable the Regional Probation Directors to lead a successful implementation of improved
collaborative working at a local level with every member of staff having the knowledge and confidence
to work with agencies and third sector providers to improve mental health and substances misuse
outcomes for those in the criminal justice system. Within your specific area, this means the creation of
new community integration teams specifically to deal with these areas of work.
Thank you for bringing these matters of concern to my attention. Please be assured that learning from
the circumstances of this tragic death will also be shared more widely with colleagues across the NPS
Divisions.
Yours sincerely / Yn gywir
Director General of Probation and Wales, HM Prison and Probation Service
Cyfarwyddwr Cyffredinol y Gwasanaeth Prawf a Chymru, Gwasanaeth Carchardai a Phrawf EM
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