Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0057, written 13 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Feb 2023 |
|---|---|
| Reference | 2023-0057 |
| Deceased | Michael Poulton |
| Coroner | Ian Singleton |
| Coroner area | Wiltshire and Swindon |
| Category | 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.
HM Senior Coroner for Wiltshire and Swindon Date: 13 February 2023 Case: 155722 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Wiltshire Police 1 CORONER I am Ian Singleton the Area Coroner for Wiltshire and Swindon 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http ://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 25 June 2019 the Senior Coroner Mr David Ridley commenced an investigation into the death of Michael POUL TON then aged 60. The investigation concluded at the end of the inquest. The conclusion of the inquest was suicide, the medical cause of death being 1a Hanging 1b 1c II 4 CIRCUMSTANCES OF THE DEATH Deceased had been in police custody following a domestic matter. He was released following enquiries on 22/6/19 and due to concern for his welfare, arrangements were made, for him to be taken by police transport to a family members home. There was a delay in the transport attending , which he was not made aware of. Some 2 hours after being released, he left the custody suite and was seen walking on the A350. The following day he was found suspended by a ligature in a field by the A350 at Yarnbrook. The police have submitted an OIPC referral regarding this matter. SEE ATTACHED FORM 65 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. - [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) People are being taken into Police custody, some distance from their home address, without having any money or means of communicating with family, or ready access to transport from the custody suite, to their home address. (2) It is requested that the position is reviewed as to what arrangements might be made to facilitate the return of people to their home address from the custody suite. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Wiltshire Police 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 12 April 2023. l, 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 . 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 13 February 2023 &f' Ian Singleton Area for Wiltshire and Swindon
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.
WILTSHIRE POLICE Mr Ian Singleton Her Majesty’s Area Coroner For Wiltshire & Swindon Wiltshire & Swindon Coroner’s Office Endless Street Salisbury SP1 1DP Date: 12 April 2023 Dear Mr Singleton Police Headquarters London Road DEVIZES Wiltshire SN10 2DN Inquest touching upon the death of Mr Michael Poulton I am writing to you on behalf of the Chief Constable and in response to your Regulation 28 Report to Prevent Future Deaths dated 13 February 2023. In anticipation of the closure of Melksham Custody in February 2023, Wiltshire Police (‘the Force”) have developed and implemented a scheme entitled the Vulnerable Detainee Transportation Scheme. The Vulnerable Detainee Transportation Scheme focuses on ensuring that detained persons (“DPs”) are able to return home safely at the earliest opportunity following their release from custody. This process starts from the DPs initial arrest via a “Ring B4 U Bring Scheme”, whereby a Prisoner Transport Team (“PTT”)/ Police Officers tasked to convey a DP to custody are also tasked with obtaining details of the DPs family/ friends and ensuring that DPs are in possession of phones, means of payment and medications etc., at that early stage. This information is to be captured on the Detainee Handover Form. The Vulnerable Detainee Transportation Scheme also requires scrutiny of a DP’s ability to use public transport and makes provision for a taxi home at the expense of the Force, depending on an assessment of the individual DP’s risk level for harm and their vulnerability, as defined by the Police & Criminal Evidence Act Code G. For the most vulnerable DPs, the police will convey them home and an additional Detainee Release Details template has been added to the custody detention log for the purpose of such an assessment. The form includes details such as the name of the Community Policing Team (“CPT”) Sergeant requested to arrange a lift home for the DP, the time they were contacted, what was agreed, the transportation’s expected time of arrival and whether the DP has been informed about this. Once a request for transportation has been made, the on-duty Custody Officer is required to remind CPT Sergeants that PTTs/Police Officers tasked to transport DPs home from Custody are not to be diverted/delayed other than in exceptional circumstances. On the rare occasions when PTTs/Police Officers are diverted or delayed, CPT Sergeants must contact the on-duty Custody Officer to discuss this and make alternative travel arrangements for the DP. The on-duty Custody Officer must then ensure that the DP is updated with any change/ delay to their lift home. The Ring B4 U Bring and Vulnerable Detainee Transportation Schemes are intended to be permanently in place across the Force area going forward. I can also confirm that details of these schemes have been disseminated Force-wide via the Corporate Communications team’s E-Briefs, as well as being highlighted to the Chief Inspector and Inspector cohorts, Custody Sergeants, Detention Officers, Variable Hours Detention Officers and Custody Co-ordinators. Training on these schemes will be given to all new Custody Sergeants. Details of the schemes are also located on the Force’s SharePoint intranet site, which is accessible to all police officers and police staff. I enclose with this letter copies of the following: 1. Ring B4 U Bring Scheme Briefing 2. Vulnerable Detainee Transportation Scheme 3. Detainee Handover Form 4. Detainee Release Form 5. Detainee Release details template May I conclude by again extending our sincere condolences to Mr Poulton’s family for his loss. I hope that the details of the aforementioned schemes implemented by the Force will reassure you and Mr Poulton’s family that we have fully addressed the issues raised during the course of his inquest. Yours sincerely , Mst(Cantab), CMgr FCMI T/Assistant Chief Constable Local Policing and Specialist Operations
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