Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0355, written 21 Oct 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 Oct 2021 |
|---|---|
| Reference | 2021-0355 |
| Deceased | Richard Franks |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (Eastern) |
| Category | Other related deaths · Suicide (from 2015) · 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 (1) THIS REPORT IS BEING SENT TO: David Ake & Co Solicitors, Falk House, Westgate, Leeds 1 CORONER I am Kevin Mcloughlin, Senior Coroner for the Coroner area of West 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. 3 INVESTIGATION and INQUEST On 17 April 2019 I commenced an investigation into the death of Richard Gordon Franks, aged 39. This concluded on 19 October 2021 when a jury returned a narrative conclusion recording a finding of suicide based upon the post mortem evidence that the cause of death was 4 CIRCUMSTANCES OF THE DEATH Mr Franks was remanded in custody on 29 December 2018 and remained in HMP Leeds until his death on 12. April 2019. On 11 April 2019 he appeared at Leeds Crown Court. He was seen in conference that morning by his solicitor and counsel at which time he was said to be in a highly agitated state and to indicate he was likely to commit suicide if sentenced to two years imprisonment. On his return to prison at approximately 17:00 hours he reported erroneously that he had been sentenced to five years imprisonment when in fact his case had been adjourned for sentencing at a later date. Mr Franks was last seen alive at approximately 20:25 hours when locked in his single occupancy cell. At approximately 06:00 hours the following morning, 12 April 2019 he was found dead in his cell. A post mortem examination attributed his death to 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) Mr Franks had a known history of self-harming and suicide attempts. His emotional state when seen at court on 11 April 2019 was triggered at least in part to his reaction to a development in the prosecution brought against him which he had not foreseen. His statement that he was likely to commit suicide was not communicated to either the security staff at the court or the prison staff. In consequence, the prison staff had no information concerning the events which took place at court. (2) Mr Franks somehow perceived that he had been sentenced to five years imprisonment, which was not the case. This false impression caused him to be in distress prior to being locked in his cell around 19:00 hours. (3) Had information concerning his emotions at court been relayed to the prison staff, this may have triggered a decision to open an ACCT - the process by which a Prisoner is subject to increased monitorinq and su ooort. In the event no 1 checks were made on him for some 10 hours. (4) At a previous hearing on 25.02.17 Mr Franks had made a comparable threat to kill himself as a result of what he perceived to be an adverse development in the case brought against him. At time his signed consent authorising information to be passed to the prison was obtained and communicated to the prison. that (5) The benefit of relaying helpful information to the prison intended to protect Mr Franks, does not seem to involve a breach of professional privilege. It would have been sufficient to request that the prison staff assess Mr Franks for themselves on his return in view of (unspecified) developments at court that day. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 Friday 17 December 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:- , Mother of Mr Franks 1. 2. HM Prison, Leeds, FAO: Governor 3. Practice Plus Group (formerly Care UK Ltd), FAO: 4. Dr , Locum GP, HMP Leeds I have also sent it to:- 1. 2. The Law Society, The Law Society's Hall, 113 Chancery Lane, London 3. The General Council Of The Bar, 289-293 High Holborn, London , Park Square Barrister Chambers 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. Dated: Thursday 21 st October 2021 9 l f_ \ ~ - KEViNM~ UGHLI; Senior Coroner West Yorkshire (E ) 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.
DAVID AKE & Co. Criminal Defence Solicitors & Mental Health Law Specialists Ground Floor, Falk House, Westgate, Leeds LS1 2RA Web Site: www.davidake.co.uk 14 December 2021 Office of the Senior Coroner Coroner’s Office and Court 71 Northgate Wakefield WF1 3BS Dear Sirs Inquest touching the death of Richard FRANKS (deceased) We are in receipt of documentation sent to us in October 2021. We would comment as follows in relation to Regulation 28 – Report to Prevent Future Deaths. The statement of confirms she attended Leeds Crown Court on the morning of 11 April 2019. The case involving Mr Franks was listed as a Floating Trial (there was no specific court allocated or hearing time). She was in company with , who was representing Mr Franks. During conference Mr a Barrister, Franks appeared in an agitated state and made a threat to end his life if he received a sentence of two years imprisonment. However, Mr Franks managed to calm down sufficiently to provide his barrister with instructions that he would plead guilty to the Prosecution case. It was clear at this stage the case would not proceed to trial and there was no indication as to when the case was to be called on (floating trials are n ot always reached). It was agreed with Counsel that an application to adjourn would be made for the reasons below and there was no reason to anticipate that this would not happen. On that basis Miss O’Connell did not wait within the court building and counsel agreed to forward his note of the hearing if the case was called on. Authorised and Regulated by the SRA SRA No: 00076234 The case was called on in the afternoon and came before His Honour Judge Bayliss QC (we anticipate that the Coroner will have requested and been provided with a copy of the court transcript). Mr Franks was represented in court by his barrister. In light of our concerns and those expressed in the letter (22 March 2019) of , Senior MH Nurse, HMP Leeds, the barrister representing Mr Franks asked the court for an adjournment of the case to allow for Mr Franks to be assessed by Probation and a Psychiatrist. This was granted and Sentence was listed to tak e place on 9 May 2019. Mr Franks was present in court and would have heard the Def ence application to adjourn. In the circumstances, it is difficult to see how Mr Franks formed the view that he had been sentenced to five years’ imprisonment. We were unaware that Mr Franks believed he had been sentenced. The previous hearing was in February 2019 (as indicated in our statement). It was after that hearing that we contacted the prison regarding Mr Franks threat to self- harm. We received their reply in March 2019. The Regulation (page 2) refers to a previous hearing on 25 February 2017. The Regulation which was provided to the Press conveys the impression that we took no action as a result of Mr Franks’ threats made at court in February 2019. With respect, this is an unfortunate typographical error. We were surprised to hear that the prison had put Mr Franks on a short-term ACCT when they were aware that he had a history of self-harm and were notified of our concerns regarding his recent threat to self-harm. We anticipate that, on his return to the prison, Mr Franks would have presented in an agitated state bearing in mind he believed erroneously he had received a 5-year prison sentence. We respectfully agree with the jury conclusion that the prison, having a duty of care and being aware of his previous history of self -harm and suicide attempt, should have placed Mr Franks on an ACCT for his own safety. We only learned that Mr Franks had taken his own life when our instructed psychiatrist contacted the prison to arrange an appointment to assess Mr Franks and was informed, he was no longer at HMP Leeds. We accept there are lessons to be learned. We have always endeavoured to follow the correct protocol when threats of self-harm are made by clients. However, we will ensure that we remind appropriate organisations each time a threat to self-harm is repeated. Yours faithfully PARTNER
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