Mark Castley

Acting Director (Courts and 
Tribunals) 
Royal Courts of Justice, 
Strand, London 
WC2A 2LL 

www.gov.uk 

3 February 2022 

Senior Coroner Harris, 
London Inner London South Coroner’s Court. 
1 Tennis Street, 
London 
SE1 1YD 

Dear Mr Harris, 

Subject: HMCTS review of risk management in respect of defendant self-
poisoning 

I am writing, as the senior Civil Servant with overall responsibility for court and tribunal 
operations, to update you on the actions we have taken following the Inquest into the 
death of Mr Mark Castley (aka Mark Marshall). 

Our initial response was to conduct a thorough review of our standards and procedures 
aimed at managing the risk of a defendant appearing at court (having been on bail) 
who has secreted something on their person with the intent of self-harm/poisoning (as 
happened in this sad case). 

The review and its conclusions and recommendations (a copy of which is attached to 
this letter) have been endorsed by the HMCTS Senior Management Team and has 
followed engagement with all stakeholders, including input from the Judicial Security 
Committee. The Chief Magistrate is also being made aware.  As part of the review, 
HMPPS (through its Prisoner Escort & Custody Services (PECS) team) also reviewed 
relevant PECS supplier standard operating procedures to ensure they align. 

Methodology 
The defendant’s journey through court was broken down into eight stages (from 
arriving at the front entrance, passing through security screening, public areas, into the 
courtroom and surrender into custody). 

Each stage was individually reviewed, risk assessed, and conclusions recorded.  The 
broad approach followed was as follows: 

  The starting point was the identification of known potential risks and threats 

present at each stage. 

  The current baseline safety controls in place to manage the risk were then 

identified; this included present security policy and arrangements. 

  The remaining or ‘residual’ risk at each stage for self/harm the adulteration of 

drinking bottle (if any) was then explored. 

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   This enabled consideration of whether additional, practical and proportionate, 

security controls could be identified so as to manage the risk further. 

You will note that there are significantly different operational arrangements and 
significantly lower risks in the magistrates’ courts which has led to our conclusion that 
some of the mitigations that might be applied in the Crown Court (such as enhanced 
dock controls) are not necessary or reasonably practicable in the lower courts.  Full 
details of operational and legal reasons for that position are provided in the reviewed 
risk assessment. 

That said, the review identified two additional controls which have been approved for 
implementation within the next few months: 

1.  On arrival at the front entrance 

Aim: To enhance HMCTS security procedures and provide a more reliable, 
effective level of deterrent and detection of prohibited items on the person; and 
to manage the risk of non-metallic prohibited items being brought into court, that 
could then be used as a weapon or to self-harm. 

Control Measure: Implementation of a random manual search requirement at 
the front entrance so as to (i)  enhance HMCTS security procedures and 
provide a more reliable/effective level of deterrent and detection of prohibited 
items on the person; and (ii) to further reduce the risk of non-metallic 
prohibited items being brought into court, that could then be used as a weapon 
or to self-harm 

Random searches will be publicised on HMCTS web pages and at the court to 
maximise the deterrent effect.  This procedure would not apply to those court 
users exempt from a search, such as those registered on the Professional 
Court User Access Scheme. 

We are aiming to fully implement an updated Security and Safety Operating 
Procedure 4b across all crime courts by the end of May.  While this seems 
some way away, this is based on our assessment of the time we will need to 
undertake a number of essential enabling activities (including local site risk 
assessments/surveys, development and dissemination of new operating 
instructions, potential court security officer redeployment, and 
communications/engagement with court users to alert them to the changes). 

2.  Public Areas 

Aim: To enhance safety arrangements in the precincts of court buildings. 

Control Measure:  To further enhance safety arrangements, HMCTS is 
currently implementing a new Safeguarding policy. This will include training, to 
be developed and delivered within the next few months, for front line court staff 
dealing with the public, such as ushers and clerks on how to identify court user 
safeguarding concerns more generally and how to ensure they are dealt with or 
escalated/communicated more effectively and consistently. 

We have developed the HMCTS Safeguarding policy, with PECS input, who 
have their own safeguarding policy/training programme for court custody staff, 
which is independently reviewed by Her Majesty’s Inspectorate of Prisons 
(HMIP).  These arrangements will embed the need for effective co-ordination 
and co-operation between all those discharging safeguarding responsibilities at 
court. 

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 I hope this is of assistance but we stand by to provide further information should this be 
required. 

Yours sincerely, 

Acting Courts and Tribunals Director 

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Mr Andrew Harris 
Senior Coroner 
London Inner South Jurisdiction  

By email  

Director General of Probation, Wales and Youth  
 HM Prison and Probation Service 
3rd Floor Churchill House 
Churchill Way 
Cardiff CF10 2HH 

  15 February 2022 

Dear / Annwyl Mr Harris 

 Inquest into the death of Mr Mark Castley 

Thank you for your Regulation 28 report dated 22 December 2022 following the inquest into the 
death of Mr Castley which concluded on the 8 December 2021. 

I know that you will share a copy of this response with the family and I would first like to express 
my sincere condolences for their loss. 

Following the Inquest, you raised the following overall concern; 

‘The  evidence suggests that his risks of recurrent impulsive  self-harm in situations his  ex-wife 
described as “when he is cornered” were not fully assessed as applying to the time after he was 
being sentenced and if they had been, a notification form might have been completed. Wh ether 
this  was  due  to  the  policy  requiring  imminence  of  risk  at  the  time   of  assessment  or  being 
erroneously interpreted so, or whether the projection of imminence arising in a future context was 
not fully considered, is not clear.’ 

Thank you for bringing these concerns to my attention.  Upon receipt of your report a number of  
actions have been undertaken to address the concerns raised.  

1)  Appendix 1 of the ‘Working with Suicide & Self -Harm; A Guide for Probation Staff’ has been 
reviewed and the question ‘is there an immediate risk of suicide’ has been changed to ‘has 
a current concern relating to suicide risk been identified’ (staff are reminded to consider 
historic information which could be relevant to, or triggered by current circumstances ). 

2)  The text above in brackets has now also been added to the Probation EQUiP process map 
for court staff to trigger the completion of a Suicide Risk Form where a concern has been  
identified.  The  Probation  Service  use  a  process  called  EQUiP  which  holds  all  national 
policies, processes and guidance, including process maps. 

3)  All  probation  staff  in  London  have  been  reminded  of the requirement  to adhere to the 
‘probation risk to self’ EQUiP process maps, including the completion of the Suicide Risk 
Form, where a current concern is identified. This directive will also be disseminated across 
the Probation Service nationally.  

                                                               
 
 
 
 
 
 
 
  
 
    
 
  
 
 
 
 
 
 
 
 
 4)  A new thematic Suicide and Self-Harm Performance and Quality Newsletter was published 
by London Probation  on 19 January 2022.  This has been emailed directly to all London 
staff in order to increase awareness of suicide prevention practice and required actions.  

I wish to assure you that HMPPS and the MOJ are committed to improving awareness in this area. 
As  part  of  our  Probation  National  Suicide  Prevention  Action  Plan  additional  relevant  actions 
include: 

•  A  current  project  with  the  Zero  Suicide  Alliance  to  develop  a  specific  online  short 
awareness training for probation practitioners to increase knowledge and raise awareness 
and confidence when asking about suicide 

•  The introduction of an HMPPS Deaths Under Supervision Working Group to improve the 

way that we learn from deaths. 

The  learning  from  this  inquest  will  inform  future  training  and  suicide  prevention  activities  in 
HMPPS. 

Thank  you  again  for  bringing  your  concerns  to  my  attention.  I  trust  this  response  provides 
assurance that action is being taken to address the matters you have raised.  I conclude by once 
again offering my condolences to the family of Mr Castley. 

Yours sincerely / Yn gywir 

Director General of Probation, Wales and Youth, HM Prison and Probation Service 
Cyfarwyddwr Cyffredinol Prawf, Cymru ac Ieuenctid, Gwasanaeth Carchardai a Phrawf EM