Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0405, written 30 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Nov 2021 |
|---|---|
| Reference | 2021-0405 |
| Deceased | Connor Hoult |
| Coroner | Janine Wolstenholme |
| Coroner area | West Yorkshire (Eastern) |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Governor of HMP Wakefield The Minister of State for Prisons and Probation 1 CORONER I am Janine Wolstenholme 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 14th June 2019, an investigation was commenced into the death of Connor Arthur Steven Hoult, aged 24 years, who died on 10th June 2019. The investigation concluded at the end of the inquest on 28th October 2021. The medical cause of death was and the conclusion of the inquest was suicide. 4 CIRCUMSTANCES OF THE DEATH On 10th June 2019 at approximately 6.30am a prison officer did a roll check, and in the very brief observation noted Connor appeared to be , which was not unusual for Connor or other prisoners. It was assumed he was watching television. Connor’s cell was unlocked for the morning at around 8am. The second officer’s interaction was no more than a fleeting glance of one to two seconds through the observation panel, where Connor appeared to him to be At approximately 8.45am a different (third) officer relocked Connor’s cell for the morning session and thought he saw Connor television. Again, it was a glance of no more than one to two seconds through the observation panel. appearing to watch At approximately 9.50am the second officer returned to Connor’s cell to seize some unauthorised footwear. As the officer entered the doorway of the cell he was able to see . Connor was in the same position Connor was as when this officer had observed him at 8am. At the time Connor was found the level of rigor mortis and hypostasis revealed he had been deceased for a considerable number of hours. His eyes were noted to be closed by attending medics looking for, and confirming the absence of, signs of life. 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. The evidence revealed prison officers are not obtaining, nor did the prison systems require them to obtain, a response from all prisoners during welfare checks. More specifically, during the morning unlock they are not required to, and therefore do not necessarily seek to, obtain a response or otherwise engage with prisoners. In particular, no response is required, and therefore not sought, from prisoners who appear to be asleep in bed, notwithstanding the requirements of PSI 75/2011 (Residential Services). The PSI sets out the fact that residential prison staff play a key role in spotting any signs of distress and will often be the first to pick up information or signs, and should accordingly engage with prisoners in such a way that facilitates the identification of any concerns or distress. Further, paragraph 2.3 of the PSI, namely, “Output No. 3 Prisoners are supported and their daily needs are met” states that prisons are required to have, “clearly understood systems in place for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock”. In the absence of such systems prisoners in distress, or otherwise a cause for concern, may be missed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 26th January 2022. 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 Connor’s mother and partner Her Majesty’s Prison and Probation Service Her Majesty’s Inspectorate of Prisons The Prison and Probation Ombudsman The Independent Advisory Panel on Deaths in Custody 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 f orm. 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 30th November 2021
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
Janine Wolstenholme
Coroner for West Yorkshire (Eastern)
6 Park Square
Leeds
West Yorkshire
LS1 2LW
2 February 2022
Dear Ms Wolstenholme,
Thank you for your Regulation 28 report of 30 November 2021, addressed to the Ministry of
Justice and the Governor of HMP Wakefield, following the inquest into the death of Connor
Hoult on the 10 June 2019. I am responding as Director General of Prisons.
I know that you will share a copy of this response with Mr Hoult’s family, and I would first
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.
You expressed concern about the conduct and quality of prisoner checks at HMP
Wakefield. I will endeavour to address your points of concern, however it may be helpful for
me to first clarify the types of checks that staff are required to conduct on prisoners.
Roll checks are undertaken to ensure that all prisoners are present. They involve staff
counting the number of prisoners in each area of the prison at particular times of the day,
and taking any necessary action if there are any immediate concerns for a prisoner’s
welfare. Welfare checks are undertaken by staff during or shortly after unlock so they can
assure themselves of the wellbeing of prisoners. This can include verbal or physical
acknowledgements, movement in a cell or in bed, or any other indication that a person is
alive.
Further, as part of the ACCT (Assessment, Care in Custody, Teamwork) process, welfare
observations are carried out on those who are considered to be at risk of self-harm or
suicide to ensure these individuals are safe. Observations will be carried out at irregular
intervals and in the least obtrusive manner, particularly at night given the importance of
sleep for wellbeing.
In January 2020, and in response to the PPO’s investigation, HMP Wakefield issued a
Governor’s Order that set out the expectation that staff should obtain a verbal response
from all prisoners who are or appear to be awake when conducting roll checks and
unlocking procedures, to avoid waking sleeping prisoners overnight or early in the morning,
while ensuring that potential concerns are identified.
Further, and in response to your concerns, the Governor of HMP Wakefield has now
circulated a Notice to Staff reminding staff that they should assure themselves of the
wellbeing of prisoners during or shortly after unlock. Additionally, your concerns will be
discussed with the staff who gave evidence at the inquest to ensure they fully understand
the process and their responsibilities during unlock, and know how to take action should
they have any concerns about an individual’s welfare.
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 of Prisons
See every Prevention of Future Deaths report matching State Custody related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.