Prevention of Future Deaths reports · 2021

Kyle Nel

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 report22 Dec 2021
Reference2021-0426
DeceasedKyle Nel
CoronerStephen Nicholls
Coroner areaDorset
CategoryState Custody related deaths · Alcohol, drug and medication related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Hmpps (PDF)
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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