Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0006, written 5 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jan 2023 |
|---|---|
| Reference | 2023-0006 |
| Deceased | Floyd Carruthers |
| Coroner | Ian Dreelan |
| Coroner area | Birmingham and Solihull |
| Category | Other related deaths · State Custody 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
THIS REPORT IS BEING SENT TO:
1. The Rt Hon Damian Hinds, Minister of State
2.
(formerly known as The National Offender Management Service)
CORONER
Director General Chief Executive – HM Prison and Probation Service
I am Ian Dreelan, Assistant Coroner for Birmingham and Solihull
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 21 June 2021 I commenced an investigation into the death of Floyd Everton CARRUTHERS.
The investigation concluded at the end of the inquest. The conclusion of the inquest was;
Conclusion of the Jury as to the death
These are the points that the Jury have discussed and reached a unanimous decision based on
the following:-
1. The fact the Mr Carruthers died of an infected heart valve and this was from a natural condition.
2. The fact that Mr Carruthers had probably had the infection for weeks if not months.
3. Based upon the evidence heard in court, on the balance of probabilities the source of infection
was not contributed to by the pressure sores found on Mr Carruthers body.
4. A blood test was ordered on 15/05/2021 but was not carried out. Based upon the evidence
heard in court a blood test may have shown markers of inflammation and possibly infection which
could have prompted earlier intervention.
5. The Prison staff involved in delivering the regime on Lima Wing in relation to Mr Carruthers from
10/05/2021 - 29/5/2021 had 10 weeks basic training at the start of their service but had insufficient
ongoing mandatory training and understanding of the matters contained in the National Offender
Management Service, Adult Safeguarding in Prison Policy, PIS 16/2015 dated 31/3/19, to enable
them to undertake their role in compliance with that policy.
As per evidence heard in court there was no safeguarding training in place during the period of Mr
Carruthers incarceration.
6. The Prison staff on Lima Wing and the HMP Birmingham Healthcare staff took insufficient steps
to safeguard Mr Carruthers throughout the period 10/5/2021 - 29/5/2021. This includes insufficient
record keeping, handover and escalation of events, such as missed meals and not leaving his cell.
7. There were failures of Prison staff to make a referral to healthcare in response to Mr Carruthers
condition, as reflected in his overall pattern of behaviour and his presentation, between 25/5/2021-
29/5/2021
As a result the Jury have reached a conclusion that death was contributed to by neglect.
CIRCUMSTANCES OF THE DEATH
1) Mr Carruthers was diagnosed with paranoid schizophrenia in 2003.
2) Mr Carruthers was under the care of the Mental Health Team and on the whole had a good
rapport, however could become irritable if challenged on his mental health by mental health
professionals. Mr Carruthers was self aware of his condition and learnt to manage it, it is noted
that he heard voices as part of his paranoid schizophrenia diagnosis even when stable. Whilst
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compliant to taking his medication, Mr Carruthers was stable. Mr Carruthers compliance with
medication over time decreased and he subsequently stopped taking his medication.
3) Mr Carruthers was not on medication at the time of arrest and subsequent transfer to HMP
Birmingham.
4) Mr Carruthers was arrested on the 09/04/21 and was taken to Perry Barr Police Station.
5) Whilst in custody at Perry Barr Police Station, Mr Carruthers underwent a Mental Health Act
Assessment on the 10/04/21 which determined he was fit to be interviewed and did not meet the
criteria for detention under the Mental Health Act 1983.
6) Mr Carruthers arrived on remand at HMP Birmingham on 12/4/2021. He was sentenced to 66
days imprisonment on 6/5/2021.
7) Mr Carruthers underwent a reception medical screening at HMP Birmingham identifying his
pacemaker. The resulting HMP Birmingham procedure is to raise a task, for a follow up on the
pacemaker, this was not done.
The reception medical screening did not identify Mr Carruthers mental health history or the Mental
Health Act Assessment completed on the 10/4/2021. The HMP Birmingham procedure is a mental
Health Nurse Review within 48 hours, this was not done.
8) A mental health nurse attended Mr Carruthers cell on the 7/5/2021, this was triggered by
concerns raised by Mr Carruthers family, to conduct an assessment. The assessment was
completed from outside Mr Carruthers cell and was around one minute long. Mr Carruthers
declined to input, he was polite but abrupt and the Nurse deemed Mr Carruthers had capacity to
refuse mental health input.
9) Mr Carruthers was moved to Lima Wing on 10/05/2021 to a double cell. At the time of his
transfer to hospital he was a single occupant of this double cell. It is noted that Mr Carruthers had
multiple cell mates during his time on Lima Wing. From evidence heard in court, having multiple
cell mates does not trigger a Health Care review.
10) A blood test was ordered on the 15/5/2021, it is unclear why it was ordered and why it was not
undertaken.
11) There is a general agreement that during Mr Carruthers time on the Lima Wing he presented
as reserved, shy and polite; he kept himself to himself.
12) The regime on Lima Wing changed regularly due to Covid restrictions and government
regulations. It is generally accepted that the regime included a morning meal, delivered to Mr
Carruthers cell, a hot meal to be collected from the servery and association and medicine
collection.
13) A summary of interaction between Prison staff and Mr Carruthers between the 25/5/2021 -
29/5/2021 based on limited CCTV and Prison Officer statements, shown during the inquest is as
follows. Between the days of 25/5/21 and 29/5/2021, Mr Carruthers had multiple interactions with
Prison Officers summarised as including food deliveries, unlocking of his cell and officers entering
and leaving Mr Carruthers cell.
The most notable event was when we last saw Mr Carruthers leave and return to his cell on the
25/5/21 having collected his hot meal. Following this we did not see Mr Carruthers leave his cell
again.
With regards to meals - we saw Mr Carruthers collect food once on the 25/05/21, had food
delivered as customary between the 25/5/21 and 28/05/2021. Mr Carruthers did not have a hot
meal on the 26/05/21 or 27/05/21 and his hot meals bought to him on the 28/05/21 and 29/05/21.
Multiple statements show evidence of Mr Carruthers not wanting meals or association time.
14) Evidence from Prison Officer statements show no concerns or observations raised or logged
for Mr Carruthers during his time on Lima Wing up until 29/05/2021. Evidence shows that Prison
Officers failed to notice a pattern due to no written log of observations or events.
15) A Prison Officer raised concerns regarding Mr Carruthers' health on the 19/05/2021 based on
his presentation and appropriately escalated to his Custodial Manager. A Hotel 2, high est
escalation, call was made to Prison Healthcare staff, to attend which occurred
16) The Prison Nurse attended and conducted initial observations which promoted a 999 call.
17) Paramedics attended and followed appropriate care, allocating roles to facilitate transfer to
hospital and highlighting to Prison Officers that Mr Carruthers required a time critical transfer to
City Hospital to gain essential input from the cardiac team.
18) Following treatment in his cell, Mr Carruthers was transferred to an ambulance for transfer to
City hospital. Significant delays occurred in the Sterile Area of HMP Birmingham whilst paperwork,
personnel and handcuff procedure were complete - it did not contribute to the death of Mr
Carruthers
19) Upon presentation at City Hospital Mr Carruthers was extreamly unwell and was reviewed by
the cardiac team. An ultrasound of the heart was used to quickly diagnose Mr Carruthers
endocarditis and start treatment.
20) When Mr Carruthers was admitted to the Acute Medical Unit he was at the point of multiple
organ failure with septic shock, acute renal failure, hepatic failure, and delirium probably related to
sepsis and cerebral hypoperfusion.
21) Evidence suggests Mr Carruthers had staphylococcal endocarditus for weeks or potentially
months prior to his hospital admission.
Evidence suggests Mr Carruthers is likely to have developed sepsis in the 1-3 days prior to his
hospital admission, leading to septic shock and multi-organ failure on admission to hospital.
22) Mr Carruthers acute medical review led to a plan to take Mr Carruthers to New Cross Hospital,
Wolverhampton on 3/6/2021 with a view to open heart surgery. There he was reviewed by 2
Consultant Cardiac Surgeons who felt that with multiorgan failure he was very unlikely to survive
open heart surgery at that point and he was therefore transferred back to City Hospital.
23) During this time, Mr Carruthers was in a critical condition, it was noted that Mr Carruthers was
hand cuffed during the transfer from City Hospital to New Cross Hospital, at the recommendation
of the Govenor) despite multiple conversations with the Prison Officers present. This showed a
lack of consideration to Mr Carruthers medical condition and the true risk to Hospital staff and the
public.
24) Following his return to City Hospital, he became more drowsy and less responsive over the
following days. He passed away peacefully on the morning of 14/6/2021.
Following a post mortem, the medical cause of death was determined to be:
1a Cardiac tamponade. Hypostatic pneumonia
1b Haemorrhagic pericarditis
1c Infective endocarditis (implanted electronic cardiac pacemaker for 2nd degree atrio-
ventricular block).
II
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. –
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1. At the time Mr Carruthers resided in HMP Birmingham, National Offender Management
Service, Adult Safeguarding in Prison Policy, PSI 16/2015 dated 31/3/19 was in force. This policy
states at paragraph 1.10 (under the heading 'Mandatory Actions') "Governors must have systems
in place to protect adult prisoners from abuse and neglect". At paragraph 2.4 the policy states
"Neglect also includes self-neglect, which covers a wide range of behaviour such as neglecting to
care for one's personal hygiene, health or surroundings and behaviour such as hoarding". My
concern is that while there is a national policy dealing with safeguarding, to include instances of
self-neglect, no adequate training exists at either national or local level to ensure the effective
implementation of that policy.
2. While evidence was heard from prison staff detailing a number of potential escalation routes
for what might be termed 'social isolation' (an instance, as with Mr Carruthers, where they had not
left their cell for a period of days but had not declared they were self isolating), notably ACCT and
CISP, none of the officers appeared aware of a corresponding process for raising safeguarding
issues. The known escalation routes (ACCT and CISP) are more focussed on violence and self-
harm, leaving at the very least a conceptual gap in how best to deal with injurious activity which is
neither violent nor directly/obviously contributory to self-harm, such as self-neglect. My concern is
that the existing safeguarding escalation process is either inadequate, inappropriately trained or
both
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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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
2 March 2023. 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:-
Mr Carruthers' Family
Birmingham Community Healthcare NHS Foundation Trust
Birmingham & Solihull Mental Health NHS Foundation Trust
I have also sent it to the Prisons & Probation Ombudsman, HM Inspectorate of Prisons
and the Independent Advisory Panel on Deaths in Custody who may find it useful or of
interest.
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.
5 January 2023
Signature:
Ian Dreelan
Assistant Coroner for Birmingham and Solihull
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.
Mr Ian Dreelan
Senior Coroner
Birmingham & Solihull’s District
The Birmingham and Solihull Coroner’s Court
Steelhouse Lane
Birmingham, B4 6BJ
Dear Mr Dreelan
21 March 2023
Thank you for your Regulation 28 report of 5 January 2023, following the inquest into the death of
Floyd Carruthers on 14 June 2021. I am responding as the Director General of Operations for His
Majesty’s Prisons and Probation Service (HMPPS).
I am aware that you will share a copy of this response with the family of Mr Carruthers, 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.
You have raised concerns about a lack of training on safeguarding policy, and in particular a lack of
awareness amongst staff of the means of escalating an issue of self-neglect, as opposed to one of
self-isolation.
On 9 March 2023, the Governor at HMP Birmingham issued a notice to staff on the subject of
safeguarding, stating very clearly that when a prisoner is found to be neglecting their own welfare it is
the responsibility of staff to ensure that appropriate action is taken to ensure that their needs are met
using relevant processes and to provide ongoing support. Staff are reminded to report such instances
to the prison safeguarding lead (the Head of Safer Custody) who will consider the suitability of making
a referral for a social care assessment.
In addition to this, safeguarding is now a standing item at the weekly Governing Governor’s briefing at
HMP Birmingham. The establishment’s suicide and self-harm prevention trainers have been
instructed to place more emphasis on issues relating to self-neglect, and from December 2023 a
HMPPS training programme focused specifically on safeguarding will become available.
The HMPPS National Social Care Board – a partnership group, involving the Department of Health
and Social Care, NHS England and the Association of Directors of Adult Social Services alongside
HMPPS policy and operational leads – is developing a workplan based on seven agreed priorities,
one of which is to improve safeguarding practice in prison and approved premises. The findings from
your report will be used to inform the activities needed to deliver this commitment.
In the meantime, HMPPS will issue a learning bulletin that will remind staff of the existing
requirements to identify and refer for assessment prisoners who appear to be self-neglecting, and
describe the actions that staff can take to support prisoners in such circumstances.
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 Operations
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