Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0106, written 7 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Apr 2022 |
|---|---|
| Reference | 2022-0106 |
| Deceased | Nicholas Rose |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| Category | State Custody related deaths · Alcohol, drug and medication 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 (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.
, Governor of HMP Guys Marsh Prison
1 CORONER
I am Brendan Joseph Allen, Area 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 28th May 2019, an investigation was commenced into the death of Nicholas
Tom Rose, born on the 18th June 1981.
The investigation concluded at the end of the Inquest on the 24th March 2022.
The Medical Cause of Death was:
la Airway Obstruction
lb Aspiration of Gastric Content
le SF-MDMB-PINACA ("Spice'') Intoxication
The conclusion of the Inquest recorded by the jury was that Nicholas Tom Rose
died as a consequence of misadventure.
4 CIRCUMSTANCES OF THE DEATH
Nicholas Tom Rose was a serving prisoner at HMP Guys Marsh at the time of his
death. He was a resident on Jubilee Wing. On Sunday
May 2019 at
approximately 8.45 am at the morning "unlock", a welfare check was conducted.
Mr Rose was in in bed in his cell at this time. At 12.15pm, when the roll call was
conducted, Mr Rose was found deceased in his cell on Jubilee Wing. Mr Rose was
still in bed. A post mortem examination, including toxicological analysis of samples
of fluid, revealed that Mr Rose had consumed "Spice" prior to his death, which
led to the aspiration of gastric content and airway obstruction.
19th
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. During the inquest evidence was heard that:
i. When Mr Rose's cell was unlocked on the morning of 19th May 2019
at approximately 8.45 am and the welfare check was conducted,
the evidence given was that Mr Rose responded with a "grunt".
Evidence was also heard regarding the "Notice to Prison Officers"
number 191/2017, issued on 30th August 2017, which requires that
a verbal response is elicited from a prisoner during a welfare check.
The corresponding "Notice to Prisoners" number 083/2017, issued
on the same day, instructs prisoners that they "must give a verbal
response such as Good Morning/Afternoon, Hello".
Evidence was heard that a "grunt" in response to a welfare check
is considered acceptable, and fulfils the requirement for a "verbal
response".
ii.
2.
I have concerns with regard to the following :
i.
I am concerned that accepting a "grunt" as a verbal response to a
welfare check does not fulfil the requirement as set out in the
Notice to Prison Officers mentioned above. Such a response gives
very limited information upon which a prison officer can assess a
prisoner's welfare. Accepting such a response potentially loses
sight of the purpose of a welfare check, which must be to check
that the prisoner is alive, immediately safe and well; that is, that
they are conscious, breathing, not in a state of distress, not in a
state of intoxication and that there are not any other factors that
might require immediate intervention to prevent harm. A verbal
response to a welfare check allows a prison officer to assess if a
prisoner has responded in an appropriate manner, giving an
indication as to whether the prisoner retains the cognitive function
to provide an appropriate response. A "grunt" does not allow such
an assessment. Therefore, I have a concern that future deaths
could occur if accepting such a response remains the accepted
practice.
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, namely 2nd June 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) Harding Evans Solicitors on behalf of Mr Rose's family;
(2) Hill Dickinson LLP on behalf of Practice Plus Group;
(3) Government Legal Department on behalf of the Ministry of Justice
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
7th A ril 2022
Bren
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 Email: 15 June 2022 Brendan Joseph Allen Area Coroner for the area of Dorset Town Hall, Avenue Road Bournemouth Dorset BH2 6DY Your Ref: 172872 Dear Mr Allen, Thank you for your Regulation 28 report of 7 April 2022, received on 26 April, addressed to the Governor of HMP Guys Marsh following the inquest into the death of Nicholas Rose on 19 May 2019. I am responding on behalf of HMPPS as Director General of Prisons. I know that you will share a copy of this response with the family of Mr Rose 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 a concern in relation to the level of response required from a prisoner during the welfare checks conducted when prisoners are unlocked to assure staff that there are no issues of concern. Residential staff play a key role in keeping prisoners safe and effective welfare checks can identify signs of distress, incidents where staff assistance may be required, and medical emergencies. Prison Service Instruction (PSI 75/2011 Residential Services) sets out the requirement on all establishments to have in place appropriate arrangements and clearly understood systems for staff to assure themselves of the wellbeing of prisoners through welfare checks. I understand that evidence was given at the inquest that HMP Guys Marsh’s local arrangement is that staff must receive a verbal response from prisoners during welfare checks and at unlock, and that notices to staff and prisoners have been issued setting out this requirement. I have received assurance from the Governing Governor that further notices to staff and prisoners were published in May 2022, following the inquest, to serve as a reminder of the expectations during welfare checks that a verbal response must be obtained, not a grunt, and that if a verbal response is not obtained then staff must access the cell to check on the welfare of the prisoner. Notices to staff and prisoners will now be re- published regularly and compliance checks are carried out by wing Custodial Managers (CMs) who observe officers unlocking prisoners to ensure that welfare checks are being carried out correctly, and this is recorded each day in wing diaries. A review of the assurance checks is carried out on a monthly basis by the Head of Residence and any member of staff who fails to meet the required standard is challenged through the HMPSS performance management process. HMP Guys Marsh has introduced toolbox talks for Prison Officers (short subject-specific training sessions) and this has included training with regard to welfare checks. The last session was completed in March 2022 as part of a safety awareness month held for all staff. Welfare checks will continue to feature as part of all relevant safety based training events. Prison officers undertaking initial training (currently known as New Officer Apprentices) are trained to conduct checks and the training emphasises the requirement for officers to confirm the safety and welfare of prisoners during roll checks, unlocks, and welfare checks. 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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