Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0337, written 25 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 | 25 Oct 2022 |
|---|---|
| Reference | 2022-0337 |
| Deceased | John White |
| Coroner | Graeme Hughes |
| Coroner area | South Wales Central |
| Category | Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME D HUGHES
HIS MAJESTY’S
SENIOR CORONER
SOUTH WALES CENTRAL
CORONER AREA
CORONER’S OFFICE
THE OLD COURTHOUSE
COURTHOUSE STREET
PONTYPRIDD
CF37 1JW
ANNEX A
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 Chief Constable of South Wales Police
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CORONER
I am Graeme D Hughes, Senior Coroner for the coroner area of South Wales Central.
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.
INVESTIGATION and INQUEST
On 5 November 2019 I commenced an investigation into the death of John Henry WHITE. The investigation
concluded at the end of the inquest on 20/10/2022.
The conclusion of the Jury was: -
We as a jury have come to the conclusion of suicide, to which a failure to release the ligature sooner
possibly contributed to chances of survival.
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
The medical Cause of Death was found to be:-
1a Hypoxic Brain Injury
1b Hanging
1c
II
CIRCUMSTANCES OF THE DEATH
These were recorded as:-
On the 20th October 2019, John Henry White suspended himself
released and transferred to the Royal Glamorgan Hospital where he died on 23rd October 2019.
Police were in attendance. John was eventually
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The Inquest focused upon: -
A. How, and in what circumstances Mr White came about his death
B. The unavailability of issued equipment (primarily ligature cutters) to the response officers attending upon
Mr White leading to an extended period of suspension by ligature.
The jury found that this omission to act to cut the ligature had possibly contributed to his death.
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. In June 2020 the Independent Office for Police Complaints recommended that all response vehicles be
equipped with a ligature cutter or similar.
That recommendation was accepted by Chief Superintendent Clare Evans on behalf of South Wales Police in
July 2020.
I received evidence from Chief Inspector
widen the scope of the recommendation to all frontline officers. She informed me that ligature cutters were
delivered to the force in July 2022.
that in 2020 South Wales Police had determined to
As at the 4th of October 2022, approximately 25% of those had been distributed to frontline officers.
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
She was unable to assist the court with the timeline for the remaining distribution other than in relation to
her own force division - a target date of the 22nd of October 2022.
She candidly accepted in her evidence that the incomplete distribution to all frontline officers at this time
meant that the scenario faced by the response officers attending upon Mr White on the 20th of October
2019 was still patent & the opportunity to release a suspended individual currently dependent upon
whether there had been distribution to the tasked response officers.
That is the concern that I have and wish you to consider and address.
2. A collateral concern, not directly causative of Mr White’s death, arose during the inquest and which I also
wish to bring to your attention.
This concerns the availability of bespoke training to response officers in relation to handling similar
situations faced by the officers on the 20th of October 2019.
The three attending officers on 20.10.19 indicated that they had not received specific training
(notwithstanding the evidence I received from retired Detective Chief inspector
a video for officers covering this type of scenario as part of mental health awareness training in 2017) to
assist them in managing the scenario they faced.
that he had prepared
Retired Detective Chief Inspector
the force for the purposes of cascading the same widely.
indicated that he had delivered training that year to officers within
Given both the statistical and anecdotally evidenced increase in mental health crisis incidents (on occasions
resulting in death) that your officers are required to attend, I believe that it would be of benefit to those
officers who have not received this bespoke training, (as well, perhaps those who may benefit from
refreshing their knowledge) for consideration to be given to reinstating the same and expediting its delivery
widely – i.e. to all frontline staff.
I would stress that the two immediate response officers cannot be, nor indeed were, criticised in their
individual interactions with Mr White on the 20th of October 2019. Indeed, and without the apparent
benefit of the training, they interacted with Mr White in accordance with the approach advocated by retired
Detective Chief inspector
.
ACTION SHOULD BE TAKEN
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In my opinion action should be taken to prevent future deaths and I believe you and your organisation have
the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 20th
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.
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
COPIES and PUBLICATION
I have sent a copy of my report to Mr White’s family, The College of Policing (for their consideration & wider
dissemination) and (possibly former) Deputy Assistant Commissioner,
IOPC’s recommendation in 2021) who may find it useful or of interest.
(who was seized of the
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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.
25 October 2022
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SIGNED:
H M Senior Coroner for South Wales Central Coroner Area
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
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