Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0172, written 12 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 May 2023 |
|---|---|
| Reference | 2023-0172 |
| Deceased | Angela Craddock |
| Coroner | Jacqueline Devonish |
| Coroner area | Cheshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: (1) (2) Ministry of Justice (3) HM Prisons & Probation Service , Director, HMP Altcourse 1 CORONER I am Jacqueline DEVONISH, Senior Coroner for the coroner area of Cheshire 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 03 May 2018 I commenced an investigation into the death of Angela Vanessa CRADDOCK aged 40. The investigation concluded at the end of the inquest on 12 May 2023. The conclusion of the inquest was that: Angela Craddock was unlawfully killed when the offender remained unlawfully at large. 4 CIRCUMSTANCES OF THE DEATH On 3 April 2018 the offender was released from HMC Altcourse on a licence. The offender was subject to a licence condition to attend at the local community rehabilitation team upon release. There was also in place a Restraining Oder for the protection of Angela Craddock. When the offender failed to present himself the local rehabilitation team issued a recall to prison for breach of the licence condition. On 6 April 2018 a recall notice was authorised by the National Offender Management Service and sent to the police to enforce. Police resources were such, at that time, that no patrol was effectively deployed to locate him. The offender attended the address of Angela Craddock where he inflicted upon her survivable injuries. She died on 11 April 2018. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: The offender had not been subject of any pre-sentence or post sentence review following conviction on 19 February 2018 for possession of a knife and a section 39 assault on Angela Craddock. The offender was sentenced to 6 months imprisonment and the Restraining order was granted for 12 months. During the 39 days between conviction and release the offender phoned Angela Craddock on 160 occasions. Most of the calls did not connect. The offender also wrote several letters to Angela Craddock from prison in breach of the Restraining Order. Details of the Restraining Order were sent to HMP Altcourse and on receipt a paper copy of the conditions were placed in an envelope to be delivered to the Public Protection Department. This was never received so the relevant staff were not aware of the Regulation 28 – After Inquest Document Template Updated 30/07/2021 Restraining Order. Consequently, upon release on licence the community rehabilitation service were unaware of the breaches of the Restraining Order and were unable to include this information in the OASYs risk assessment or the prison recall report and review, ultimately sent on to the police for the enforcement of the recall notice. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 July 07, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Cheshire Constabulary National Probation Service Representatives of the former Cheshire Rehabilitation Company Family I have also sent it to who may find it useful or of interest. , Chair, Domestic Homicide Review I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 12/05/2023 Jacqueline DEVONISH Senior Coroner for Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
7th July 2023 Ms Jacqueline DEVONISH Senior Coroner for Cheshire Dear Ms Devonish, Inquest into the death of Angela Craddock Thank you for your Regulation 28 Report, issued following the Inquest into the death of Angela Craddock, addressed to the Ministry of Justice and HM Prison & Probation Service. I am replying as the Director General Operations of His Majesty’s Prison and Probation Service (HMPPS). I know that you will share a copy of this response with the family and I would first like to express my sincere condolences for their loss. Every death in these circumstances is a tragedy and the implementation of learning from this is an absolute priority. You have raised matters of concerns in the following terms 1. The offender had not been subject of any pre-sentence or post sentence review following conviction on 19 February 2018 for possession of a knife and a section 39 assault on Angela Craddock. The offender was sentenced to 6 months imprisonment and the Restraining order was granted for 12 months. Response – Since this sentencing exercise took place, Cheshire HMCTS has introduced Dedicated Domestic Abuse Courts (DDAs) to deal specifically with domestic abuse related offences. HMCTS, the CPS, and Cheshire Police and Probation Services are working together to improve information sharing and to ensure that Sentencers have all the relevant and necessary information, assessments and advice to deal appropriately with these cases in Court. Cheshire Probation provides a dedicated Court Duty Officer to work in the DDA Court each day to ensure all necessary enquiries are made and sufficiently focused and detailed reports for sentencing purposes are provided. 2. During the 39 days between conviction and release the offender phoned Angela Craddock on 160 occasions. Most of the calls did not connect. The offender also wrote several letters to Angela Craddock from prison in breach of the Restraining Order. Details of the Restraining Order were sent to HMP Altcourse and on receipt a paper copy of the conditions were placed in an envelope to be delivered to the Public Protection Department. This was never received so the relevant staff were not aware of the Restraining Order. Response - I am aware that you have also addressed your Report to the prison and the Governor will be able respond to this specific matter of concern in relation to the prison’s own internal processes. Please be assured that Probation and Prison Services share learning and review ways to improve practice on a regular basis. 3. Consequently, upon release on licence the community rehabilitation service were unaware of the breaches of the Restraining Order and were unable to include this information in the OASYs risk assessment or the prison recall report and review, ultimately sent on to the police for the enforcement of the recall notice. Response - At the relevant time, the post sentence supervision was being delivered by the Cheshire & Greater Manchester Community Rehabilitation Company Limited (CRC) and the separation of the delivery of probation supervision had added to the complexity of arrangements to share information between prisons and probation. The CRCs ceased to hold contracts to deliver probation services on the 25th June 2021 and there is now one Probation Service. This has simplified and therefore improved the sharing of information between releasing prisons and the receiving probation service area. In addition to the specific responses set out above, it may be of assistance for you to note that HM Inspectorate of Probation has just published a thematic inspection of work undertaken, and progress made, by the Probation Service to reduce the incidence of domestic abuse and protect victims. This includes a number of recommendations for both HMPPS and the Probation Service and will be considered with care and attention and an action plan prepared to respond to the recommendations. Of particular note, the Report includes sections on assessment and planning and sentence delivery which are relevant to the issues of concern you have raised and learning from the specific issues you have raised will be taken into consideration in the preparation of an action plan. Thank you for bringing these matters of concern to my attention. Please be assured that learning from the circumstances of this tragic death will be shared more widely with colleagues across all the Probation Service Regions. Yours sincerely,
Director HMP Altcourse Higher Lane Fazakerley Liverpool L9 7LH Date: 7th July 2023 Senior Coroner Jacqueline Devonish BA (Hons), DipFMS Office of His Majesty's Coroner County of Cheshire Dear Mrs Devonish Regulation 28: Report to prevent future deaths Angela Craddock (Deceased) Thank you for your Regulation 28 report of 24th May 2023 addressed to me as the Director of HMP Altcourse. I know that you may share a copy of this response and I would first like to express my condolences to Angela's family for their loss. Every death is a tragedy and keeping the public safe is a priority for us as a prison that serves the courts of Merseyside and Cheshire. HMP Altcourse was made aware of the circumstances of Angela's death by the OHR back in 2018. As a result of that communication a review of our systems and procedures was undertaken. This found that at that time a copy of the court documents normally arrived with the prisoner and court services team on admission into the prison. These documents would be sent up to our custody records department and any public protection matters i.e. a restraining order would be photocopied and a copy sent to the Public Protection Team. Once received a member of the team would follow it up by interviewing the offender and explaining the restrictions . Once completed restriction of phone calls and written correspondence would be put in place. This did not happen on this occasion as the Public Protection Team had no evidence of ever receiving the restraining order in the internal post as per our process. This then meant restrictions were not put in place and relevant agencies were not aware of the Restraining Order. A series of actions were then put in place to ensure we had assurance of no future reoccurrence. Those actions were: All documents including restraining orders, warrants, and PERs are photocopied by our Admissions department upon receipt from the court services provider and collected the following morning by a member of the Public Protection Team who will sift any relevant risks, implement the relevant restrictions, and update the warnings on our local Custody Management System/P Nomis systems. Any complete mail/ call monitoring requests are forwarded to the Head of Offender Management Unit for approval. HMP Altcourse Higher Lane Fazakerley Liverpool L9 7LH Tel: 0151 522 2000 Sodexo Limited - No 842846 - England - Registered Office - One Southampton Row - London - WC1 B 5HA www.sodexo.com 5T01' HUNGER A.Sodu.olnlbatr.-r sodex o * QUALITY OF LIFE SERVICES As further assurance the Custody Department upon receipt of a restraining order will scan the order and email it to the functional mailbox for OMU/Public Protection Unit and an evidence trail is kept of those sent documents. This was put in place to prevent any internal mail failures or the Public Protection Team not collecting items from Admissions. Since 2018 the Prison has gained access to probation and court documents via N Delius, Digital Prison System and the Common Platform (Courts). These systems give us significant information to allow staff completing Public Protection risk assessments to have access to live and up to date information. This further improvement in our systems gives us confidence that a repeat occurrence will be avoided in the future. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that actions have been taken to address this matter and prevent reoccurrence. Yours sincerely, Director HMP Altcourse
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