Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0001, written 5 Jan 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jan 2022 |
|---|---|
| Reference | 2022-0001 |
| Deceased | Ian Miller |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | State Custody related deaths · Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ministry of Justice 2. The Governor of Her Majesty's Prison Usk 1 CORONER 2 3 I am Caroline Saunders, Senior Coroner for the Area of Gwent CORONER'S LEGAL POWERS 1 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 INVESTIGATION AND INQUEST On 27/9/2019 an investigation was opened into the death of Ian Anthony Charles Miller The investigation concluded at the end of the inquest on 9/12/2021 when a jury determined the following: The conclusion of the inquest was recorded as a narrative in the following terms Ian Miller was serving a term at Her Majesty's Prison Usk and was due for release on 27th October 2019. On 20th September 2019 Ian attended a probationary meeting during which he was informed that he would not be able to live at the family home or with his father-in- law. He could not have unsupervised contact with his children, and he might be homeless. Key persons present at the meeting did not have a prior relationship with Ian and did not know how devastating this news would be to him, and he was not placed under closer supervision. On 21st September 2019 Ian Miller took his own life by suicide. Ian . Despite efforts by prison staff and the emergency services, Ian could not be revived, and he died in the prison at 16:55 hours. 4 5 The medical cause of death was: 1a) Hypovolaemic shock 1b) Bleeding from radial artery . CIRCUMSTANCES OF THE DEATH The circumstances of Ian Miller's death are set out in the narrative provided by the jury and need no further explanation. 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 statutory duty to report to you. The MATTERS OF CONCERN are as follows: - 1. (cid:9) The management of medication prescribed to prisoners. At post mortem examination the toxicologist determined that there were a number of drugs in Ian's blood and urine that he had not been prescribed. The court was informed that at HMP Usk, all prisoners are required to be capable of managing their own medication. The medications are not kept in a locked facility. The evidence provided clearly indicated that prisoners were trading prescribed medication which had become a form of currency within the prison. Ian's former cellmate indicated this practice was rife and indeed Ian bought medication from other prisoners. Evidence was heard from the Governor / Head of Safety at HMP Usk who informed the court that he was not aware of this practice, and it appears this was also not known by the prison officers. The court was informed that there is a system of randomised checks in place within the prison to attempt to determine whether prisoners are appropriately managing their medication, however prisoners have clearly found ways around this. Whilst the ingestion of unprescribed medication did not contribute to Ian's death, this practice, if left unchecked, clearly puts the lives of other prisoners at risk in the future. 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. I should be grateful if the following information be provided to me: 1. (cid:9) Confirm the steps that the prison is taking to address the risks posed by prisoners at HMP Usk trading prescribed medication. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 02/03/22 I, the Coroner, may extend this 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 necessary. 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Ian Anthony Charles Miller 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 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 DATE 05/01/22 Signed Caroline Saunders Her Majesty's Senior Coroner for the Area of Gwent.
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.
HM Prison & Probation Service Ms Caroline Saunders HM Senior Coroner for Gwent By email Probation Service Director General of Probation, Wales and Youth HM Prison and Probation Service 3rd Floor Churchill House Churchill Way Cardiff CF10 2HH 28 February 2022 Dear / Annwyl Ms Saunders Inquest into the death of Mr Ian Miller Thank you for your Regulation 28 report of 5 January 2022, addressed to the Ministry of Justice and the Governor of HMP Usk, following the inquest into the death of Ian Miller on the 21 September 2019. 1 am responding as Director General of Probation, Wales and Youth. I know that you will share a copy of this response with Mr Miller'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, following evidence heard at the inquest, about the trading of prescribed medication and you have asked for confirmation of the steps that the prison is taking to address this, in order to reduce the risks. In December 2021, the Deputy Governor and the Head of Healthcare undertook a review of the in- possession medication process. This included reviewing the compact which is agreed between the prisoner and the healthcare provider, the Aneurin Bevan University Health Board, when any medication is distributed. As a result of the review, the prisoner induction process was updated in January 2022 to include key information on the process of in-possession medication, the dangers of misusing prescription drugs, and instructions to report any concerns with staff. Staff were also reminded during briefings to ensure that the compact is fully reviewed and signed by all prisoners during their inductions. In order to ensure that staff are aware of this issue and the risk that prisoners trading prescribed medications presents, the Deputy Governor issued guidance to staff in January 2022 highlighting what they must look out for, and the importance of recording any instances of this immediately including informing the healthcare provider. This notice will be re-issued annually to continually raise staff awareness and ensure that new staff are also informed. Any intelligence received about instances of prisoners trading medication will continue to be monitored and collated by the security department and considered during the weekly staff security briefings to ensure that all staff are aware of emerging trends and risks. Increased measures have been introduced in areas of high risk across the prison, this includes the recycling department which now has more detailed security risk assessments for all prisoners that work there, due to them potentially coming into contact with discarded medications. Amnesty bins have also been added to the wings to ensure that medications may be disposed of correctly, when required. Random medication checks have been increased to 10% of the prison population and are conducted monthly by both healthcare and prison staff. The checks are to ensure that a prisoner has the correct in-possession medication in the right quantities and any discrepancies are immediately addressed through medication reviews. The mandatory drug testing (MDT) is also in place which provides initial screening for six types of drugs. If a prisoner that is prescribed medication receives a positive MDT result, the prison will then liaise with healthcare to seek confirmation with the laboratory whether this was caused by the prescribed medication. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter. Yours sincerely / Yn gywir Director General of Probation, Wales and Youth, HM Prison and Probation Service Cyfarwyddwr Cyffredinol Prawf, Cymru ac Leuenctid, Gwasanaeth Carchardai a Phrawf EM
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