Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0020, written 24 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 | 24 Jan 2022 |
|---|---|
| Reference | 2022-0020 |
| Deceased | Idris Habib |
| Coroner | Patricia Harding |
| Coroner area | Mid Kent and Medway |
| Category | State Custody related deaths · Mental Health 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.
Mid Kent and Medway Coroners Cantium House County Hall Sandling Road Maidstone Kent ME14 1XD Telephone New and Current Cases: 03000 410502 General Enquiries: 03000 410503 Email: kentandmedwaycoroners@kent.gov.uk Date: 24 January 2022 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HMP Swaleside (care of Government Legal Department) 1. CORONER I am Patricia Harding Senior Coroner for Mid Kent and Medway 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 28 November 2018 I commenced an investigation into the death of Idris HABIB. The investigation concluded at the end of the inquest . The conclusion of the inquest was Narrative: Idris Habib took his own life when he hung himself in his cell, B1 - 18, but his intention in doing so is unclear. On 16th November 2018 Idris Habib set a fire in his cell and stated that he wanted to kill himself. There was a failure to open an ACCT following this, however it can not be concluded that these factors contributed to his death. 1a Hanging 1b 1c II 4. CIRCUMSTANCES OF THE DEATH Idris Habib was transferred to HMP Swaleside from HMP Pentonville on 15.11.2018. There were no issues identified on induction in respect of his mental or physical health, there was however a history of Habib expressing to prison staff that he was being bullied and threatened and requests to be moved or segregated. Shortly after arrival at HMP Swaleside Mr. Habib indicated that he wanted to be moved from the induction wing as he was under threat from the people that he had been transferred from HMP Pentonville with. On 16.11.2018 he summoned assistance because he had cut himself whilst fashioning a weapon from plastic cutlery that he stated he needed for protection. An hour later he set fire to his cell. On both occasions he stated that he was being bullied. He stated at one point that he wanted to kill himself but did not repeat this when subsequently questioned following these events. He was given reassurance about his safety and was moved to a different wing. The prison investigated Mr. Habib's concerns and found no evidence to support the allegation of bullying or threats. Over the next few days and 'self-secluded', rarely leaving his cell. Two other prisoners (one a mentor) agreed to look after him and provide him with support. At 7am on 20th November 2022 he was seen at the back of his cell at the early roll call. He was in the same position when the mentor prisoner went to see him and realised he was suspended. Cell B1-18 had been recently vacated by another prisoner and police who searched the cell after the death found containers belonging to a previous occupant. Quetiapine and trihexyphenidyl hydrochloride containers were empty when found but a box of simvastatin contained a blister pack with 7 tablets inside. It is not known whether the other containers were empty when Idris Habib was placed in the cell. Toxicological tests conducted following the death was negative for these substances. 5. CORONER’S CONCERNS During the course of the inquest the 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) Medication from the previous occupant of cell B1-18 was found in the cell following the death of Mr Habib (2) There was a disconnect between HMP Swaleside's local policy and the Prison Officer Entry Level Training in respect of roll checks (3) That measures put in place following Mr. Habib's death to ensure welfare checks are conducted are not overlooked and are documented as having taken place 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. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23rd March 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 -Solicitors acting on behalf of the family, Healthcare services at the prison 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. 24 January 2022 Signature Patricia Harding Senior Coroner for Mid Kent and Medway
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
Patricia Harding
Senior Coroner for Mid Kent and Medway
Cantium House
County Hall
Sandling Road
Maidstone
Kent
ME14 1XD
30 March 2022
Dear Ms Harding,
Thank you for your Regulation 28 report of 24 January 2022 following the inquest into the
death of Idris Habib on 20 November 2018. I am responding as the Director General of
Prisons.
I know that you will share a copy of this response with Mr Habib’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 have raised three concerns regarding cell clearance procedures, roll checks and
welfare checks, which I will address in my response.
In November 2021, HMP Swaleside issued a notice reminding staff of the process to be
followed when undertaking cell clearance checks to ensure that any items belonging to
previous occupants are removed before the next prisoner is moved to that cell. Any
medication found should be placed into a security bag and an intelligence report must be
submitted. The notice also reminded staff that a pre-occupancy check should be undertaken
and documented before the cell is allocated to another prisoner. This process was also
reinforced during staff briefings.
In respect of staff checks on prisoners, it may be helpful for me to first clarify the types of
checks that staff are required to conduct on prisoners.
Roll checks are undertaken as a fundamental security check to ensure that all prisoners are
present in each area of the prison at particular times of the day. While the primary purpose
of these checks is to ensure all prisoners are accounted for, staff are required to take any
necessary action if there are any immediate concerns for a prisoner’s welfare.
Welfare checks are undertaken by staff during or shortly after unlock so they can assure
themselves of the wellbeing of prisoners. This can include verbal or physical
acknowledgements, movement in a cell or in bed, or any other indication that a person is
alive and there are no obvious issues of concern. Further, as part of the Assessment, Care
in Custody and Teamwork (ACCT) process, welfare observations are carried out on those
who are considered to be at risk of self-harm or suicide to ensure these individuals are safe.
Observations will be carried out at irregular intervals and in the least obtrusive manner,
particularly at night given the importance of sleep for wellbeing.
All prisons are required to have a local policy which sets out what staff are required to do
during checks, in order to ensure the above requirements are met. Local instructions and
policies will supersede training individuals may have had as they set out the expectations of
that individual establishment.
I fully recognise the implications of any checks not being carried out as they should be.
HMPPS would expect staff to take swift action if they have any concerns about an
individual’s welfare no matter what type of check is being conducted.
Since Mr Habib’s inquest, HMP Swaleside has introduced a welfare check that staff conduct
at approximately 8am. Staff must open the cell door and ensure they gain a verbal response
from the occupant so they can assure themselves of the prisoner’s wellbeing. The
completion of the check must be recorded in the wing assurance book. Additionally, the
prison has re-issued a notice to remind staff that they must satisfy themselves that the
prisoner is alive and gain a verbal response when completing welfare checks. This has also
been highlighted during full staff briefings that take place three times a week.
I hope the measures outlined above provide you with reassurance that learning and
appropriate action has been taken from the circumstances of Mr Habib’s death.
Yours sincerely,
Director General of Prisons
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