Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0322, written 18 Oct 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 Oct 2022 |
|---|---|
| Reference | 2022-0322 |
| Deceased | Robert Evans |
| Coroner | Kirsten Heaven |
| Coroner area | Swansea and Neath Port Talbot |
| Category | State Custody related deaths · Suicide (from 2015) |
| 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:
The Governor of HMP Swansea, 200 Oystermouth Road, Swansea
1
CORONER
I am Kirsten Heaven, Assistant Coroner, for the coroner area of SWANSEA NEATH &
PORT TALBOT
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 14 January 2018 an investigation was commenced into the death of Robert Lee
Evans, a prisoner at HMP Swansea, who was found deceased in his cell in the early
hours of 14 January 2018 after having tied a ligature around his neck. He was 37 years
of age at the time of his death. The investigation concluded at the end of the inquest on
13 October 2022.
The medical cause of death was:
1a pressure on neck (hanging)
The conclusion of the inquest was a narrative conclusion as follows:
Considering the information that was known to the prison about Lee, the prison probably
failed to adequately assess his risk of suicide and self-harm.
During the period from lock up to midnight only, there was probably not an adequate
system of checks in place for Lee in light of the fact that he was undergoing alcohol
detoxification and on the induction wing and in the early days prison. This probably
made a more than minimal contribution to Lee's death.
The prison doctor probably failed to review Lee's medical notes sufficiently. This
probably made a more than minimal contribution to Lee's death.
The prison doctor probably failed to prescribe Lee's antidepressant medication. This
possibly made a more than minimal contribution to Lee's death.
The prison doctor probably failed to prescribe Lee's detoxification medication. This
probably made a more than minimal psychological contribution to Lee's death.
The systems and processes in place probably contributed to the failure of the health
staff reviewing all records.
The prison and medical staff within the prison probably did not take all appropriate steps
to safeguard Lee when he was in prison custody, for example by not opening an ACCT,
and by the way prescription information was communicated to Lee. This probably made
a more than minimal contribution to his death.
1
4
CIRCUMSTANCES OF THE DEATH
The deceased was Robert Lee Evans
On Sunday 14 January 2018 (in the early hours) Lee was founded
just over 24 hours after his arrival into
HMP Swansea. Lee was in a cell on his own at his own request. Lee had been released
on licence from HMP Swansea on 29 January 2017. When arriving in HMP Swansea
Lee was undergoing detoxification from alcohol and had been given certain medication
under the patient group directive both in police custody and then in prison. There were
historic risk markers for suicide and self-harm on the PER from police custody and on
NOEMIS – the prison system. The PER recorded anxiety and depression and that Lee
had not had his anti-depressant medication for several days. Lee was not on an ACCT.
There was evidence in prison medical records showing that Lee had been prescribed
anti-depressant medication for depression and anxiety when in HMP Swansea on
previous occasions and that on 29 January 2017 Lee was released from HMP Swansea
with a month’s supply of this medication. On Saturday 13 January 2018 the prison
doctor reviewed Lee’s notes but did not prescribe Lee’s anti-depressant medication and
did not write up Lee’s prescription for his alcohol withdrawal medication. Lee was told
that the doctor had not written up his alcohol withdrawal prescription and this made Lee
anxious at the medication hatch. However, at the nurse’s discretion Lee was given his
evening dose of his alcohol withdrawal medication. Shortly afterwards Lee can be seen
on CCTV speaking to two prison officers in an animated way and for approximately one
minute. I have been unable to establish what Lee was saying. Shortly after this
interaction Lee can be seen walking in the direction of the area that houses the post box
holding a piece of paper and envelope and then returning to his cell empty handed. Lee
was locked in his cell at around 4.30 and was not checked until he was founded
suspended by a nurse commencing the first of three nightly checks shortly after
midnight. After Lee’s death a letter was found in the HMP Swansea post box written by
Lee to his partner which indicated that at an earlier time Lee was fine but on the other
side Lee had written “they stopped my meds goodbye I quit loved you”. It was clear from
the evidence that this letter could only have been posted on the Saturday.
5
CORONER’S CONCERNS
During the inquest the evidence revealed matters giving rise to a 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 make a report under paragraph 7, Schedule 5 of the Coroners
and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013
The first MATTERS OF CONCERN is as follows:
. I am aware that
Her Majesty’s Chief Inspector of Prisons 2018 inspection report in respect of HMP
Swansea stated that. “there have been four self-inflicted deaths since the previous
inspection, all within a week of arrival. This replicated findings at our previous inspection
of Swansea” [S5]. The most current report of Her Majesty’s Chief Inspector of Prisons
dated 2020 states, “There had been two self-inflicted deaths since the last inspection,
the most recent in December 2019. Both had occurred soon after the prisoners arrived
at the prison” [1.23]. I have heard evidence that it is well known by prison staff and
recognised in national Ministry of Justice policy and in HMP Swansea Prison Policy that
the very early days are a particularly high-risk time for prisoners particularly those on
remand or recalled on licence. This is supported by the findings of the above inspection
report.
I heard that there is a safer cell on the induction unit and in that cell the whole
window unit has been replaced with plastic material that can be slid to allow prisoners to
get air from the outside into the cell. I heard evidence that prisoners are not on the
2
induction unit for a significant period but that prisoners in the induction unit are in a
vulnerable time in custody as they have just arrived in prison.
The second MATTERS OF CONCERN is as follows:
I heard evidence from the two prison officers who appear in the HMP Swansea CCTV as
mentioned above. On the evidence I have seen these witnesses were the last members
of prison staff Lee spoke to before his death. At all stages into the investigation into
Lee’s death (prisons and probations ombudsman and coronial) these witnesses have
stated that they are unable to assist with what Lee was saying to them hours before his
death. I am concerned that immediately following Lee’s death and the following day that
these highly material witnesses (who were on duty) were not spoken to, did not attend a
hot or cold debrief and were not asked to make a first account of events when matters
were fresh in their minds. These witnesses did become known to the PPO. As a result,
my investigation into Lee’s death has been significantly hampered. I am therefore
concerned that lessons may not have been fully learnt from the circumstances of Lee’s
death.
I am concerned that if evidence relevant to a death in custody is not immediately
captured and considered a situation may be created where evidence is lost which
prevents general lessons from being learnt from a death in custody and that this creates
a risk that other deaths will occur.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe 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 by 15 December 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, The Ministry of Justice, Swansea Bay University Health Board and those
representing Lee’s family (
Canter solicitors).
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
20 October 2022
3
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 of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Ms Kirsten Heaven HM Assistant Coroner for Swansea Neath & Port Talbot The Guildhall Swansea SA1 4PE 08 December 2022 Dear Ms Heaven, Thank you for your Regulation 28 report of 20 October 2022, addressed to the Governor of HMP Swansea and myself. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations. I know that you will share a copy of this response with Mr Evan’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 expressed concerns regarding at HMP Swansea and the capturing of evidence immediately after a death in custody. in the safer cell on the induction unit As you have described, the unit within the safer cell on the induction unit has been replaced with plastic material that can be slid to allow prisoners to gain air from the outside into bars as a ligature point the cell. This function reduces the risk of an individual utilising the and, in certain cases, those who are assessed as presenting with higher or imminent risk of suicide will be located there. Whilst replacing the in the normal cells on the induction unit at HMP Swansea with those described will mitigate the risk of individuals using as ligature points, it would not make these cells ligature-resistant. Therefore, the suggested action will be made at a prohibitive cost as we do not consider that the change will achieve its intended outcome of mitigating all risk. Staff recognise that prisoners may feel vulnerable during their early days in custody and HMPPS uses the Assessment, Care in Custody, Teamwork (ACCT) case management approach to support people at risk of self-harm and suicide. As part of any case review, those present will consider the prisoner’s location and whether any possessions need to be removed or returned, and this may include moving the prisoner to a ligature-resistant cell if appropriate. HMP Swansea has multiple ligature-resistant cells that are available to locate prisoners who are assessed as being at imminent risk of self-harm or suicide. At a national level, HMPPS is undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible, including from the The review will include their build standards and how they are used to support prisoners in crisis. Our aim is to ensure that cells that are fitted with ligature-resistant features are available as an option for staff managing prisoners in crisis, and that they retain those features in full working order and do not deviate from the standard over time. At this point it is too early to say what new rules may be introduced, such as setting the frequency of maintenance, although we do recognise that cells are subject to constant wear and tear and need frequent attention to keep them up to standard. I recognise the importance of ensuring that any evidence relating to deaths in custody is preserved, including the recollections of staff who have had recent interactions with the deceased individual. Prisons are required to have contingency plans in place that include debriefs with staff who were on the scene at the time of the incident, but these will not be the only staff to have had potentially relevant contact with the prisoner. We are currently drafting a new HMPPS Policy Framework, updating the policy for prisons to follow in the event of a death in custody, and within this will include guidance for prisons to ensure that staff who have relevant information are identified and prompted to make a record of this at an early stage. This will ensure that it is available at a later date, even if they are not required to give a police statement or interviewed by the Prisons and Probation Ombudsman (PPO) as part of their investigation. 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, Director General of Operations
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