Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0318, written 21 Sep 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Sep 2021 |
|---|---|
| Reference | 2021-0318 |
| Deceased | Charlie Todd |
| Coroner | James Thompson |
| Coroner area | County Durham and Darlington |
| Category | State Custody 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 THIS REPORT IS BEING SENT TO: 1. Governor - HM Prison Durham 1 CORONER I am James E Thompson, assistant coroner, for the coroner area of County Durham & Darlington 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 9th September 2019 I commenced an investigation into the death of CHARLIE BRIAN TODD, 18 years. The investigation concluded at the end of the inquest on 9th September 2021. The conclusion of the inquest was Misadventure. The medical cause of death was; 1a Pressure On Neck 1b Hanging The Jury set out their findings as; Mr Charlie Brian Todd was in HMP Durham and was admitted to SACU on 2/9/19 just after 10am that day. He was found by staff members in his cell at 16:04 hanging by a ligature around his neck. Resuscitation was commenced but was unsuccessful and unfortunately, he was pronounced dead at 1652 on 2/9/19. 4 CIRCUMSTANCES OF THE DEATH On 2nd September 2019 Mr Todd, a prisoner at HMP Durham , was subject to an adjudication hearing which resulted in him being awarded a period of cellular confinement within the Segregation & Care Unit (SACU) within the same prison. He was confined in a cell within the SACU that morning and was to be the subject to regular hourly checks. At just after 4pm the same afternoon he was discovered to have ligatured in his cell and despite efforts to resuscitate him, he died at 4.52pm that day. 1 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – During the course of the inquest evidence was heard from a number of witnesses of the supervision and staffing arrangements within SACU. The overall position was that there was no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed, and officers, including officers not posted to the SACU, but covering for a shift, were required to allocate various tasks between themselves on an adhoc basis. On the 2nd September 2019 the document setting out which hourly checks had been undertaken in the SACU was incomplete. No check on Mr Todd’s cell took place at 3pm that day. Evidence was heard that staffing levels can vary, with officers being occupied on tasks which meant hourly checks could not always be completed. Whilst there is auditing of the hourly checks retrospectively, there is no ‘real time’ system which would alert officers and their supervisors to checks being incomplete for a prisoner/s as the record of checks are paper based and held in the SACU, as well there is no constant supervising officer present or other system there to ensure compliance. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 15th November 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Messrs BLM on behalf of G4S Messrs Hill Dickinson on behalf of Spectrum Messrs Ison Harrison on behalf of l I have also sent it to the Prisons & Probation Ombudsman who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 Signed: James E Thompson Dated: 21st September 2021 3
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 E Thompson Assistant Coroner for County Durham & Darlington HM Coroners Office PO Box 282 Bishop Auckland Co Durham DL14 4FY 15 November 2021 Dear Mr Thompson Thank you for your Regulation 28 report of 21 September 2021, addressed to the Governor of HMP Durham, following the recent inquest into the death of Charlie Todd at the prison on 2 September 2019. I am responding as Director General of Prisons. I know that you will share a copy of this response with Mr Todd’s family and I would like to first express my condolences for their loss. Each death in custody is a tragedy and the safety of those in our care is my absolute priority. You express concern regarding the staffing and supervision arrangements within the Separation and Care Unit (SACU), and completion of the required hourly checks. I can assure you that there is clear management oversight of the SACU. The day-to-day running of the unit is directed by a dedicated Custodial Manager (CM), responsible for the allocation of tasks and performance management of the officers working there. The CM reports to, and is supported by, the Head of Residence and Safety (a Governor grade) who forms part of the Governor’s Senior Management Team. The running of the SACU is further subject to daily checks undertaken by the Orderly Officer and Duty Governor, and the Governor undertakes a weekly in-charge check. I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU’s regime, and allow for the required checks to take place. The staffing of the SACU is in line with national benchmarking standards, and indeed the Governor has provided an additional officer resource, as well as an administration staff member in order to support the work of the SACU. HMP Durham have a weekly Regime Management Plan meeting which forecasts staffing levels for the following week to ensure that the regime across the prison is delivered and consistent. It is inevitable that at some points staff who are not normally based in the SACU will be required to work on the unit for a shift, and in order to support those staff in understanding the expectations of the unit a “Know Your Job” sheet will be provided to them, setting out the tasks they will be required to cover. Additionally, the SACU CM has been tasked with overseeing the daily and weekly management checks being carried out and will also provide an update to the Head of Residence, so that any reoccurring issues can be promptly addressed as appropriate with individual staff. A recently commissioned SACU pilot, considering operational processes within the SACU and the management of segregated prisoners, will provide the prison with an opportunity to improve paperwork and will also be used to look at the health support provided on the unit with feedback used to strengthen current practices. Given the number of checks that take place throughout the prison on a daily basis, implementing a ‘real-time’ system to ensure these have been done would require significant and prohibitive resource. I believe that the robust assurance processes already in place, together with the improvements made will ensure that prisoners located in the SACU at HMP Durham, can be safely managed. Thank you again for bringing these matters of concern to my attention and for your suggestions, and I hope this provides you with the reassurances that you seek. Yours sincerely, Director General for Prisons
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