Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0426, written 22 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 | 22 Dec 2021 |
|---|---|
| Reference | 2021-0426 |
| Deceased | Kyle Nel |
| Coroner | Stephen Nicholls |
| Coroner area | Dorset |
| Category | State Custody 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.
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. 2. Service , Governor, HMP Guy's Marsh , Chief Executive of Her Majesty's Prison and Probation 3. Victoria Atkins MP, Minister for Prisons and Probation 1 CORONER I am Stephen John Nicholls, Assistant Coroner, for the Coroner Area of Dorset 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 the 13th June 2018, an investigation was commenced into the death of Kyle Nel, born on the 27th February 1986. The investigation concluded at the end of the Inquest on the 14th December 2021. The Medical Cause of Death was: la Aspiration of gastric contents associated with synthetic cannabinoid (SF-ADB) also known as "Spice'') use. The conclusion of the Inquest recorded: Misadventure 4 CIRCUMSTANCES OF THE DEATH On the 9th June 2018 Kyle, a serving prisoner at HMP Guys Marsh, was found unconscious in his cell 29 on Jubilee wing by his cell mate. The alarm was raised and prison officers attended and CPR was administered, paramedics attended they continued to try to resuscitate him but Kyle was subsequently declared dead. 5 CORONER'S CONCERNS During the course of the inquest 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 duty to report to you. The MATTERS OF CONCERN are as follows: During the course of the inquest 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 duty to report to you. The MATTERS OF CONCERN are as follows; 1. During the inquest evidence was heard that: i. Concerns about Kyle, his use of PS, the bullying he was subject to and the debts that he incurred, were raised with the prison staff by his mother. Whilst his mother was able to speak to a member of the prison staff, the quality of the response gives rise to concern. The prison has introduced a number of different measures aimed at tackling anti- social behaviour and bullying. There is the Tackling Anti-Social Attitudes (TASA) policy. This is a three- tiered approach dependant on the incident. This ranged from monitoring to consideration of being moved to the segregation unit in the most serious cases. There is also the Custodial Violence Management Model (CVMM). This is a case management approach for managing violent and significantly problematic custodial behaviour. HMP Guys Marsh was the pilot for this scheme. This introduced a specific CNOMIS case note for those who were being managed under the CVMM to allow for entries to be recorded electronically. ii. Evidence was heard that between the various units at the prison there are fences but that prisoners can pass items through the fences between one unit and another. This enables drugs and other prohibited items to be transferred between units. The evidence heard is that this issue is known about but no action has been taken. 2. I have concerns with regard to the following: i) I have concerns that when members of a prisoner's family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented. ii) The security fences within the prison estate need to be reviewed and consideration urgently given to prevent drugs and other prohibited materials being passed between prisoners through the fences. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or 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, 17 February 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 and to the following Interested Persons: (1) Irwin Mitchell Solicitors (on behalf of Kyle's family) (2) , Government Legal Dept, One Kemble Street, London WC2B 4TS on behalf of the Ministry of Justice (3) , Hill Dickinson on behalf of Practice Plus Group, EDP 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 Dated Signed 22 December 2021 Stephen l Nicholls
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 16 February 2022 Stephen J Nicholls Assistant Coroner for Dorset Bournemouth Town Hall Bournemouth BH2 6DY Dear Mr Nicholls, Thank you for your Regulation 28 report of 22 December 2021 following the inquest into the death of Kyle Nel at HMP Guys Marsh on 9 June 2018. I am responding on behalf of all HMPPS recipients as the Director General of Prisons. I know that you will share a copy of this response with the family of Mr Nel 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 concerns in relation to how a prisoner’s family and friends are able to raise concerns about the health and welfare of a prisoner, and the effectiveness of existing security fences within the prison estate to prevent drugs and/or prohibited materials being passed between prisoners. I thank you for bringing your concerns to my attention. I note that you heard evidence on the Custodial Violence Management Model (CVMM), a case management approach used for managing violent and problematic behaviour. HMP Guys Marsh were a pilot site for this scheme, which was phased out from November 2018, when HMPPS launched the Challenge, Support and Intervention Plan (CSIP) which is the mandated violence reduction case management model that must be used across the adult prison estate. CSIP provides a framework for managing violence that is centred around the individual and targets their specific needs to help them manage and move away from violent behaviours. HMP Guys Marsh have extended the use of CSIP to provide support to victims or suspected victims of bullying, intimidation, and those who self-isolate. The intervention of a third party may be crucial in alerting staff that a prisoner is at risk, and it is important that families and friends know that any concerns raised about a loved one will be acted on appropriately and that where possible they receive feedback when they do get in touch. I have received assurance from the Governor of HMP Guys Marsh that there are now various options available to families who wish to raise concerns. Families with immediate concerns are able to contact the switchboard and be put through to the Safer Custody team or to the Orderly Officer (the senior Custodial Manager with responsibility for overseeing the running of the prison outside of the core day) if out of hours. The Safer Custody hotline and mailbox contains an out of office message with instructions on how to raise an emergency concern out of hours. All concerns raised are now logged on a database, managed by the Safer Custody team, along with a record of the action taken, and a note is placed on the individual’s NOMIS record so that information regarding a prisoner’s risk is shared with all relevant staff . The Safer Custody team respond to any concerns raised by families and friends, providing an update on what has happened and what actions have been taken. Of course, there are instances where staff are not able to provide detail for security reasons but in these circumstances an explanation is provided to families in line with the HMPPS policy framework on Strengthening Prisoners’ Family Ties. The Group Safety team carry out assurance checks to ensure that incidents are being logged and responded to in a timely manner. Additionally, all emails received which relate to the safety of prisoners or concerns raised by family and friends are kept on file so that they can be revisited if required. Where relevant an intelligence report may also be submitted so that the concern raised can be considered by security analysts for any potential risk, prompting consideration as to whether a CSIP referral is required to provide additional support to those who may be vulnerable. At HMP Guys Marsh the safety and security analysts are located in the same office to support effective information sharing. The second concern you raise recommends that consideration should be given to reviewing the security fences used within the prison estate to prevent drugs and other prohibited items from being passed between prisoners. As a category C prison, the security fences in place at HMP Guys Marsh meet the current agreed national requirements necessary to keep prisoners safe and secure. I wish to assure you that the work being carried out nationally by the Drug Strategy Team and filtered down into each establishment is focused on restricting the supply of drugs in prisons, supporting prisoners to reduce and avoid substance misuse, and providing the help and treatment they need to maintain their recovery. In order to tackle the problem of drugs in prisons, work is focused on improving security, building intelligence, and targeting the criminal networks which aim to bring drugs into prisons. Some of this work includes intelligence led checks of the internal and external perimeters and working with local police forces to identify and capture the perpetrators and intended recipients of items which are thrown over the external wall into prisons, known as ‘throw overs’. In addition to this, anyone found passing drugs or other prohibited items within establishments is dealt with in line with the standard prison disciplinary measures, and where relevant an intelligence report is submitted to help build intelligence and support the proactive work on reducing drugs getting into prisons. The national Drug Strategy and Delivery team conduct diagnostic visits, checking internal and external perimeters (including fences and gates), to identify any vulnerabilities relating to drug dealing which are reported back to establishments to take action. HMP Guys Marsh has also been included in the accelerator project, where selected prisons have received additional resources in certain areas. At HMP Guys Marsh this includes a dedicated drug strategy manager who has been in place since Autumn 2021 and is making a positive impact on the local drug strategy processes. The project has now received additional funding and will be extended for three years to further support efforts to tackle the problem of drugs in prisons. In addition to the ongoing work on restricting the supply of drugs it is vital to concentrate efforts on reducing demand and building recovery and this done through ensuring that prisoners understand the consequences of drug use, both within the prison and the wider risks to themselves and their families, and offering opportunities that give purpose and direction in order to make a positive difference to the safety of prisons as well as helping individuals to change their lives. 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
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