Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0331, written 21 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 | 21 Oct 2022 |
|---|---|
| Reference | 2022-0331 |
| Deceased | Carl Langdell |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire Western |
| Category | State Custody related deaths · Suicide (from 2015) |
| Organisation named | Midlands Partnership University NHS Foundation Trust |
| 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)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. HMP Wakefield
2. Ministry of Justice - Rt. Hon Brandon Lewis MP, Secretary of State for the
Ministry of Justice
1
CORONER
I am Kevin Mcloughlin, Senior Coroner, for the Coroner area of West Yorkshire (East)
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 Coroner's (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
On 26 February 2021 I commenced an investigation into the death of Carl Shaun
Langdell, aged 31. The investigation concluded at the end of the Inquest on 21 October
2022. The conclusion of the Inquest was a narrative recording that death was
attributable to haemorrhage from neck incision, and made findings in relation to Mr
Langdell's management by the prison authorities and healthcare provider, along with a
finding of suicide.
4
CIRCUMSTANCES OF THE DEATH
On 11 February 2021 around 00.05 Carl Shaun Langdell was discovered in his locked,
single occupancy cell with a significant wound to his neck. He was still able to speak
Despite emergency treatment he went into cardiac arrest. He was
certified dead at 01:47 on Thursday 11 February 2021 at Pinderfields Hospital,
Wakefield.
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)
(2) He had been identified by a consultant psychiatrist as at "chronic risk of suicide
attempts/self-harm attempts which is likely to remain due to the nature of his
personality disorder".
(3) In January 2021 he was observed to be acting in a bizarre and agitated manner
after refusing his prescribed medication for the previous month.
1
(4) Despite this history and the known risk he was permitted under the prevailing
rules at HMP Wakefield to be in possession
when alone in his locked cell overnight.
(5)
(6)
(7) Evidence was taken at the inquest from a Governor who indicated a national
proposal had been made
obvious risk.
6
ACTION SHOULD BE TAKEN
. If implemented this plan would remove one
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 approximately 56 days of the date
of this report, namely by Friday 16 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:
1.
2. Practice Plus Group
3.
, Midlands Partnership NHS Trust
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
21st October 2022
Signed
M{~W~
Kevin Mcloughlin
Senior Coroner
2
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
Kevin McLoughlin
HM Coroner’s Office
Senior Coroner for Yorkshire West Eastern
71 Northgate
Wakefield
WF1 3BS
23 December 2022
Dear Mr McLoughlin,
Thank you for your Regulation 28 report of 21 October 2022, addressed to the Governor of
HMP Wakefield and the Secretary of State for Justice. 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 Langdell’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.
Following evidence heard at the inquest, you expressed concerns regarding the provision of
to prisoners. Thank you for bringing your concern to my attention.
You will be aware that HMPPS uses the Assessment, Care in Custody and Teamwork
(ACCT) case management approach to support people at risk of self-harm and suicide.
ACCT is a tool that assists staff in providing multi-disciplinary care and support to
individuals at risk of harm to themselves, in order to minimise that risk.
are issued to prisoners to enable personal hygiene and care in
accordance with Prison Service Instruction 75/2011 Residential Services. Control measures
are in place through the ACCT process to ensure reasonable management of these items
where risks are raised.
During the inquest, you heard evidence that following Mr Langdell’s death, the Governor
policy and confirmed that it sets out the action
ordered a review of the prison’s local
that must be taken when staff issue prison
assessment and staff ensuring they check that the blades are present when the razor is
returned.
, which includes a risk
At a national level, we recognise the risks associated with the current
provision and are actively seeking to identify improvements to the current provision.
Throughout this year we have conducted several pilots across the prison estate, testing
alternatives to the current wet shave provision and control measures in establishments.
These pilots are due to conclude in the spring of 2023, at which time they will be evaluated
to consider any concerns or issues which may have arisen and measured against the
impact they have had on violence and self-harm. This evaluation will enable us to make
informed recommendations on future shaving provision in prison establishments.
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.
Director General of Prisons
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