Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0014, written 18 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 | 18 Jan 2022 |
|---|---|
| Reference | 2022-0014 |
| Deceased | Terance Radford |
| Coroner | Laurinder Bower |
| Coroner area | Nottingham City and Nottinghamshire |
| Category | Other 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Honourable Victoria Atkins QC MP, Minister of State (Ministry of Justice) for Prisons and Probation 1 CORONER I am Miss Laurinda Bower, Her Majesty’s Assistant Coroner for the coroner area of Nottingham City and Nottinghamshire 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 21 May 2019, I commenced an investigation into the death of Terance Alfred RADFORD, aged 87 years. The investigation concluded at the end of the inquest on 14 January 2022. The conclusion of the inquest was that: At around 09.30 hours on 19 April 2019, Mr Terance Alfred Radford was stood waiting at the bus stop on Worcester Avenue, Mansfield Woodhouse, Nottinghamshire, when he was struck by a car, driven at speed directly into collision with him, by a male driver who had taken the car from its owner shortly before the said collision. Mr Radford died at the scene as a result of his injuries. Mr Radford was unlawfully killed. 4 CIRCUMSTANCES OF THE DEATH (restricted to the circumstances relevant to this report. A full note of the findings and conclusion has been shared with this report ) On 20 April 2020, a jury sitting at Nottingham Crown Court, convicted manslaughter of Terry. of the The inquest learned that had been released from HMP Ranby , Nottinghamshire, less than 24 hours prior to Mr Radford’s death. His release from prison was contrary to the national Home Detention Curfew Policy Framework, because he was, at the material time, awaiting the resolution of an Independent Prison Adjudication, dated 13 April 2019. A decision to downgrade the level of adjudication from independent to internal, made by three Governors on 15 April 2019, not including the original decision -making Governor, had no basis in prison policy or procedure, and was driven by a desire to circumvent the terms of postponement set out within the Home Detention Curfew policy framework, in order to release Independent Adjudication was due to be heard. from custody on 18 April 2019, rather than post-29 April 2019, when the This decision provided in the circumstances described above. But for the decision to release with the opportunity to bring about the death of Mr Radford on Home Regulation 28 – After Inquest Document Template Updated 30/07/2021 Dentention Curfew, Mr Radford would not have died when he did and in the manner he did. release from prison, he was considered by prison staff to pose a risk At the time of of causing harm to others, such that he could not be safely managed on the general residential block, and instead had been detained in the segregation unit since 29 March 2019. While in the segregation unit, he had continued to engage in behaviour that placed others at risk of harm, including fire setting and assault. At the material time, the Home Detention Curfew Policy Framework did not expressly prohibit prisoners from being released early from their sentence on home detention curfew directly from the segregation unit or on account of their behaviour while in custody. The Probation Support Officer had not completed a pre -release risk assessment, and had not considered any risks associated with his release above and beyond the suitability of the proposed release address. There was no information sharing between prison, mental health services and probation staff, that considered risk of harm to others on release, in the context of a prisoner who was known to have stopped taking his mental health medication and had disengaged from mental health services, who required isolation in the segregation unit due to his repeated violent outbursts, and who had displayed unusual and bizarre behaviour in the 48 hours prior to his release. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. The national Home Detention Curfew Policy Framework permits the release of eligible prisoners directly from the Prison's segregatio n unit, in circumstances where the prisoner has been placed in the segregation unit because the elevated risk of harm they pose to staff and other prisoners cannot be safely managed within the general prison population. The public may rightly be concerned that prisoners deemed ‘too risky’ to reside within the general prison population; with its strict curfews and regime, use of locked cells, and trained prison personnel with protective gear, can still be released early from their sentence under the terms of the Policy. 2. The national Home Detention Curfew Policy does not expressly require consideration or assessment of the prisoner’s risk of harm to others, beyond the suitability of the proposed release address . If a broader assessment of risk of harm to others is anticipated by the Policy, there is no guidance on who should complete the assessment (singular or multi-agency input), when it should be completed, and what factors ought to be considered as part of that assessment. 3. The national Home Detention Curfew Policy contains no framework for multi- agency information sharing with regards to the assessment and management of risk for those deemed eligible for early release under the terms of the Policy. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by March 15, 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; Mr Radford’s family HM Prison and Probation Service Nottinghamshire Healthcare NHS Foundation Trust (Prison mental health care providers) Derbyshire Healthcare NHS Foundation Trust The Chief Constable of Nottinghamshire Police The Chief Constable of Derbyshire Police The victims of in receiving this report) conduct on 19 April 2019 (who have expressed an interest I have also sent it to The Governor of HMP Ranby The Independent Monitoring Board for HMP Ranby Prison and Probation Ombudsman HM Inspectorate of Probation, Chief Inspector, Care Quality Commission who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 yo ur response about the release or the publication of your response by the Chief Coroner. 9 Dated: 18 January 2022 Miss Laurinda Bower HM Assistant Coroner Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Miss Laurinda Bower
HM Assistant Coroner
Nottingham City and Nottinghamshire
The Council House
Old Market Square
Nottingham
NG1 2DT
Victoria Atkins MP
Minister of State for Justice
15 March 2022
TERANCE RADFORD – REGULATION 28 REPORT
Thank you for your Regulation 28 report of 18 January 2022 following the inquest into the death
of Terence Alfred Radford on 19 April 2019.
I know that you will share a copy of this response with the family of Mr Radford and I would like to express
my sincere condolences for their terrible loss. I can only imagine their pain given the terrible
circumstances of Mr Radford’s death. I should also like to express my sympathy to the other victims of
crimes that day.
Following evidence heard at the inquest you have raised three concerns about the Home Detention
Curfew Policy Framework, and I can confirm that we are taking action in relation to all three as set out
below:
The national Home Detention Curfew Policy Framework permits the release of eligible
1.
prisoners directly from the Prison's segregation unit, in circumstances where the prisoner has
been placed in the segregation unit because the elevated risk of harm they pose to staff and other
prisoners cannot be safely managed within the general prison population.
The public may rightly be concerned that prisoners deemed ‘too risky’ to reside within the general
prison population; with its strict curfews and regime, use of locked cells, and trained prison
personnel with protective gear, can still be released early from their sentence under the terms of
the Policy.
Response
I understand and share those concerns. Offenders should not be released on HDC when their
current behaviour means that they cannot be safely managed in the community. HM Prisons and
Probation Service (HMPPS) is issuing an instruction this week to prison Governors that no
prisoner held in a segregation unit may be released on HDC except where the governing Governor
themselves has determined that it would safe to do so. In making the decision, the Governor must
involve the Community Offender Manager plus key agencies involved in delivering the offender’s
risk management plan on release.
The national Home Detention Curfew Policy does not expressly require consideration or
2.
assessment of the prisoner’s risk of harm to others, beyond the suitability of the proposed release
E https://contact-moj.dsd.io/
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address. If a broader assessment of risk of harm to others is anticipated by the Policy, there is no
guidance on who should complete the assessment (singular or multi-agency input), when it
should be completed, and what factors ought to be considered as part of that assessment.
Response:
The HDC Policy Framework will be amended to ensure that consideration for HDC takes into
account the risks presented overall, and not just to those at the address.
It is important to understand that whilst the HDC Policy Framework focuses on HDC, all HDC
eligible offenders are subject to routine risk management planning applicable to offenders serving
standard determinate sentences with automatic release dates (which are, on average, around
three months after the HDC date). Release planning and risk management in such cases begins
with a start of sentence assessment under the Offender Assessment System (OASys). It is in
OASys that risk of serious harm, risk of re-offending and linked risk factors are identified,
interventions are put into a sentence plan to reduce risk of harm and reoffending, and a risk
management plan is created.
Annual reviews and pre-release work by prison and probation staff should ensure that sentence
plan work is progressed, and risk is re-assessed accordingly. Six to nine months prior to automatic
release the risk management plan is reviewed with the perspective of the approaching release
date. As part of release planning, key issues are identified, which will include accommodation
needs, requirements for mental health treatment or substance misuse services and whether
referral to the multi-agency public protection arrangements (MAPPA) is necessary.
What this means for HDC is that Offender Managers must assess, when completing the Address
Checks form, whether there is already in place an adequate plan to manage the offender safely on
release. If not, they must identify what steps are needed to put such a plan in place. No release
should occur until the plan is in place. In some cases, the plan will exclude the proposed address
as the offender cannot be managed safely there, and HDC will be refused. Changes to the HDC
Policy Framework will make clear that this approach is required in every case and will be
accompanied by communications and training to embed the message going forwards.
The national Home Detention Curfew Policy contains no framework for multi-agency
3.
information sharing with regards to the assessment and management of risk for those deemed
eligible for early release under the terms of the Policy.
Response:
The HDC Policy Framework will be amended to ensure that the necessary information-sharing
takes place before there is a decision to release on HDC.
Offenders eligible for HDC are subject to ongoing sentence and risk management planning as
described above. This involves interdepartmental and inter-agency co-operation and information
sharing, feeding into the HDC decision-making process. This did not work effectively in relation
to the release of
information from key external agencies, such as police, children’s services and health, plus
internal departments, such as prison security, is taken into account by those making
recommendations and decisions about HDC.
and changes to the Framework will focus on ensuring that
The Home Detention Curfew scheme has been running since 1999 and enables selected prisoners
serving sentences of less than four years’ imprisonment to be released early to work towards
rehabilitation in the community, while remaining subject to strict conditions, including electronic
monitoring. Those breaching its conditions on release can expect to be returned promptly to custody. It is
essential, however, that the scheme is limited to suitable offenders and I have therefore asked HMPPS to
2
prioritise the necessary amendments to the Framework so that changes not being made immediately will
be in place by the summer.
Finally, I should like to address the very serious matter you raised about the decision to withdraw a
referral of a prison disciplinary charge against
to the independent adjudicator and the
possibility that this was done in order to circumvent the HDC policy and allow for
As you rightly indicate, under the terms of the HDC Policy Framework, prisoners must not be released on
HDC until disciplinary proceedings have been dealt with by the independent adjudicator. Moreover, once
referred to the independent adjudicator, the matter may not be withdrawn.
release.
On receipt of the Regulation 28 Report, HMPPS instigated an investigation under Prison Disciplinary
powers into the circumstances of
withdraw the referral made to the independent adjudicator. At the time of writing, the investigation
process is ongoing but once it is concluded I shall write further. I thank you for bringing this to my
attention, it is very important that we establish exactly what happened so that we can offer a clear
other victims that day.
explanation, not least for the family of Terance Radford and
release including the decision made at HMP Ranby to
VICTORIA ATKINS MP
3
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