Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0423, written 21 Dec 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 Dec 2021 |
|---|---|
| Reference | 2021-0423 |
| Deceased | Saul Thomas |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | State Custody related deaths · Mental Health related deaths |
| Organisation named | Birmingham and Solihull Mental Health NHS Foundation Trust |
| 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)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Governor, HMP Birmingham, Winson Green Road, Birmingham B18
4AS.
1
CORONER
I am David Donald William Reid, HM Senior Coroner for the coroner area of
Worcestershire
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 9.5.19 an investigation was commenced into the death of Saul Richard THOMAS,
a prisoner at HMP Hewell who died in his cell at the prison on 19.5.19 having
. He was 42 years of age at the time of
his death.
This investigation concluded at the end of the inquest on 10.12.21.
The medical cause of death was:
The conclusion of the inquest was as follows:
“Saul Thomas died as a result of
not possible to determine what his intention was at the time he did this.
See Questionnaire:
1. Was Saul's mental health adequately assessed and managed by healthcare at
HMP Birmingham? NO
. It is
2. If NO to Question 1:
(a) did a failure to assess and manage Saul's mental health at HMP Birmingham
probably cause or contribute to his death on 19 May 2019? NO
(b) If NO or CANNOT SAY to Question 2(a), did a failure to assess and manage
Saul's mental health at HMP Birmingham possibly cause or contribute to his death on
19 May 2019? YES
3. Do you consider that an ACCT suicide/self-harm mitigation plan should have been
opened at HMP Birmingham on or at any stage after 11 May 2019? YES
4. If YES to Question 3:
(a) did a failure to open an ACCT on or at any stage after 11 May 2019 at HMP
Birmingham probably cause or contribute to his death on 19 May 2019? YES
(b) if NO or CANNOT SAY to Question 4(a), did a failure to open an ACCT on or at
any stage after 11 May 2019 at HMP Birmingham possibly cause or contribute to his
death on 19 May 2019?
1
5. Was the outgoing handover about Saul from HMP Birmingham to HMP Hewell
satisfactory? NO
6. If NO to Question 5:
(a) did that unsatisfactory handover probably cause or contribute to Saul's death on
19 May 2019? NO
(b) if NO or CANNOT SAY to Question 6(a), did that unsatisfactory handover possibly
cause or contribute to Saul's death on 19 May 2019? YES
7. Did HMP Hewell deal with the handover about Saul from HMP Birmingham in a
satisfactory way? NO
8. If NO to Question 7:
(a) did the unsatisfactory way in which HMP Hewell dealt with the handover probably
cause or contribute to Saul's death on 19 May 2019? YES
(b) if NO or CANNOT SAY to Question 8(a), did the unsatisfactory way in which HMP
Hewell dealt with the handover possibly cause or contribute to Saul's death on 19
May 2019?
9. Was the mental health referral made by healthcare at HMP Hewell 2019 adequate?
NO
10. If NO to Question 9:
(a) did the inadequate mental health referral at HMP Hewell probably cause or
contribute to Saul's death on 19 May 2019? YES
(b) if NO or CANNOT SAY to Question 10(a), did the inadequate mental health
referral at HMP Hewell possibly cause or contribute to Saul's death on 19 May 2019?
11. Was information shared and considered adequately by healthcare staff at HMP
Hewell? NO
12. If NO to Question 11:
(a) did inadequate sharing and consideration of information by healthcare at HMP
Hewell probably cause or contribute to Saul's death on 19 May 2019? YES
(b) if NO or CANNOT SAY to Question 12(a), did inadequate sharing and
consideration of information by healthcare at HMP Hewell possibly cause or
contribute to Saul's death on 19 May 2019?
13. Was Saul's mental health adequately assessed and managed by healthcare at
HMP Hewell? NO
14. If NO to Question 13:
(a) did the failure by healthcare to adequately assess and manage Saul's mental
health at HMP Hewell probably cause or contribute to his death on 19 May 2019?
YES
(b) if NO or CANNOT SAY to Question 14(a), did the failure by healthcare to
adequately assess and manage Saul's mental health at HMP Hewell possibly cause
or contribute to his death on 19 May 2019?
15. Should an ACCT
staff at HMP Hewell? YES
mitigation plan have been initiated by prison
16. If YES to Question 16:
(a) did the failure by prison staff at HMP Hewell to open an ACCT probably cause or
contribute to Saul's death on 19 May 2019? YES
(b) if NO or CANNOT SAY to Question 16(a), did the failure by prison staff at HMP
Hewell to open an ACCT possibly cause or contribute to Saul's death on 19 May
2019?
2
17. Was Saul Thomas' death contributed to by neglect? YES
4
CIRCUMSTANCES OF THE DEATH
In answering the questions “when, where, how and in what circumstances did Mr.
Douglas come by his death?”, the jury found as follows:
“On 19/5/19 Saul Thomas died at HMP Hewell,
cell.”
in his
To clarify, Mr. Thomas was remanded into custody to HMP Birmingham, charged with
a number of serious offences, on 15.4.19. This was his first experience of custody. He
had a recent history of drug-induced paranoia, linked to his heavy use of cocaine, and
whilst at HMP Birmingham was transferred to the mental health ward within the
Inpatients Unit, so that his mental health could be formally assessed. During his time
at HMP Birmingham, Mr. Thomas continued to express paranoid thoughts, particularly
that other people were looking to harm him and that he would be killed. Following a
court hearing on 16.5.19, he was transferred to HMP Hewell. Both prisons failed to
ensure that HMP Hewell were made aware of the concerns over Mr. Thomas’ mental
health and the fact that he was undergoing psychiatric assessment within the
Inpatients Unit at HMP Birmingham before his transfer. Once at HMP Hewell, he was
placed on an ordinary prison wing. It was recorded that he felt under threat, but didn’t
know why. On the morning of 19.5.19 Mr. Thomas was found unresponsive in his cell
at HMP Hewell, having
. He was confirmed deceased
some 30 minutes later.
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) In the questionnaire which formed part of their conclusion, the jury found that
an ACCT document should have been opened for Mr. Thomas at HMP
Birmingham at some point after 11.5.19, and that a failure so to do probably
caused or contributed to his death. I heard evidence from a senior member of
staff at the prison that as many as a third of all staff at HMP Birmingham still
and to
do not have up-to-date training relating both to
the ACCT process. I was also concerned to hear from one prison officer that
he had had no ACCT training since 2014. Until such training is provided to all
staff working at the prison, there remains a risk of similar deaths occurring in
the future;
(2) In the questionnaire which formed part of their conclusion, the jury found that
the unsatisfactory handover about Mr. Thomas provided by HMP Birmingham
to HMP Hewell possibly caused or contributed to his death. I heard evidence
from a senior member of staff at HMP Birmingham that (a) prison staff there
should have alerted their counterparts at HMP Hewell to the fact that Mr.
Thomas had been undergoing psychiatric assessment within the Inpatients
Unit there; and (b) that this was still a concern which needed to be looked
into. I was concerned to hear that, whilst this failing has been recognized by
HMP Birmingham, no action has been taken to ensure that it will not be
repeated. Until action is taken to ensure that handovers between prisons
include such important information, there remains a risk of similar deaths
occurring in the future.
3
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 by conducting an investigation into the deficiencies and
failures outlined above, and ensuring that appropriate training is provided to all
relevant staff.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 15.2.22. 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:
Deighton Pierce Glynn solicitors, who represent Mr. Thomas’ family;
Government Legal Department, who represent HM Prison Service;
Browne Jacobson LLP, who represent Birmingham Community NHS Foundation Trust
and Birmingham and Solihull Mental Health NHS Foundation Trust;
Practice Plus Group
Midlands Partnership NHS Foundation Trust;
The Prison and Probation Ombudsman.
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
Signed
-------------------------------------------------------------------------------------------------
D. D. W. Reid 21st December 2021
H.M. Senior Coroner for Worcestershire
4
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 14 February 2022 Mr David Reid HM Senior Coroner Worcestershire Coroner’s Court The Civic Martins Way Stourport-on-Severn Worcestershire DY13 8UN Dear Mr Reid, Thank you for the two Regulation 28 reports of 21 December 2021 following the inquest into the death of Saul Thomas at HMP Hewell on 19 May 2019, addressed to the Governors of HMP Birmingham and HMP Hewell respectively. I am responding on behalf of HMPPS as the Director General of Prisons. I know that you will share a copy of this response with the family of Mr Thomas 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 evidence heard at the inquest you have raised two matters of concern: staff training in the Assessment, Care in Custody and Teamwork (ACCT) process (the system by which prisoners at risk of suicide and self-harm), and the need for effective handover procedures when prisoners transfer prisons. HMP Birmingham have increased the capacity of their ACCT version 6 training, and now have a plan in place to train 80% of their staff in suicide and self-harm (SASH) over the coming six months. The training plan prioritises staff working in areas of the prison that are considered high risk, including the Care and Separation Unit (CSU), Healthcare Unit, Reception and the Reverse Cohorting Unit (RCU). To achieve this the Governing Governor has asked the Prison Group Director for additional training to be made available to reduce the number of staff requiring training. In addition, HMP Birmingham will ensure all future new staff will receive SASH training as part of their induction. HMP Hewell have advised that in December 2021 alone they delivered training to a further 205 staff in the latest version of the ACCT. Despite having been impacted by COVID-19 and its restrictions, they are continuing to work through the backlog of staff ACCT training and over the coming months expect to have trained a much larger percentage of staff. The prison has 209 staff fully trained in SASH, and a further 66 currently working through the required training modules. By the end of March 2022 HMP Hewell will have a further two members of staff trained as SASH trainers, and therefore will be able to provide more training opportunities at HMP Hewell in order to speed up the delivery. With regard to transfer procedures, a new process is now in place at HMP Birmingham for when prisoners who are being supported by healthcare, including mental health services, are being transferred to another establishment. As soon as it is known a prisoner is transferring, the healthcare team are required to make contact with the receiving prison. If this is not possible then the matter is escalated to the healthcare manager and duty Governor who are then required to ensure a handover takes place before they leave their shift. In addition to this, on the day of the transfer reception staff are required to call the receiving reception manager to notify them of a new arrival transferring from a healthcare unit. These actions will be recorded on the prisoner’s National Offender Management Information System (NOMIS) record and the new digital Prisoner Escort Record will also record any and all prisoner healthcare requirements. 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, and I would once again like to reiterate my sincere condolences to the family of Mr Thomas. Yours sincerely Director General of Prisons
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