Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0178, written 2 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jun 2023 |
|---|---|
| Reference | 2023-0178 |
| Deceased | Andrew Dean |
| Coroner | Michael Spencer |
| Coroner area | East Sussex |
| 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.
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: HMP Lewes The Ministry of Justice 1 CORONER I am Michael Spencer, Assistant Coroner for the coroner area of East Sussex. 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 29 March 2021 I commenced an investigation into the death of Andrew DEAN aged 50. The investigation concluded at the end of the inquest on 31 March 2023. The jury recorded a conclusion of SUICIDE. 4 CIRCUMSTANCES OF THE DEATH On 26th March 2021 at approximately 10.11am in cell A3-10 at HMP Lewes, Andrew Dean . He was treated was found with a ligature around his neck at the scene by prison staff, healthcare staff and paramedics. Andrew Dean was declared dead at 11.27am at HMP Lewes. 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: Following his arrival at HMP Lewes on 24 March 2021, Mr Dean was offered and attempted to make his initial ‘first night’ phone call but did not manage to speak to anyone. Over the next 36 hours, he made requests of prison staff for another opportunity to make a phone call, which were refused. During the same period, his partner tried to contact the prison through the prison switchboard, but was not able to make any contact with him. In his suicide note to his partner, Mr Dean wrote “I tried to get to talk to you but these lot here wouldn’t let me.” I am concerned that there are no clearly defined processes to ensure that new prisoners can successfully make first contact with family members (when this does not take place on the first night) and for logging and handling incoming calls to the central switchboard from family members with concerns about a prisoner’s safety and/or requesting a welfare check. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Following the inquest, I gave the Ministry of Justice an opportunity to address these concerns by providing further evidence of any new procedures that have been put in place since Andrew Dean’s death, but they declined to do so. In my view, these are matters that require further consideration by the Ministry of Justice and HMP Lewes to avoid a risk of future deaths through self-harm or suicide. I refer to the enclosed letter from the solicitors for Mr Dean’s partner dated 19 May 2023. 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 Monday 31 July 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 1. Andrew Dean’s partner 2. Andrew Dean’s brother 3. Practice Plus Group. 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: 02/06/2023 Michael SPENCER Assistant Coroner for East Sussex Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Michael Spence Assistant Coroner for the area of East Sussex Highfield Drive St Leonards on Sea East Sussex TN38 9UH Dear Mr Spence, 22 September 2023 Thank you for your Regulation 28 report of 2 June 2023 addressed to HMP Lewes and the Ministry of Justice following the inquest into the death of Andrew Dean at HMP Lewes on 26 March 2021. I am responding on behalf of HMPPS as Director General of Prisons. I am grateful to you for granting an extension for the response and apologise for the late return. I know that you will share a copy of this response with the family of Mr Dean, 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. Following evidence heard at the inquest you have raised two concerns which I will address in turn. Your first concern is about the process for ensuring that new prisoners can successfully make first contact with family members. The national policy provides for an exception to the monitoring arrangements that must be put in place for prisoner calls for “at least one initial phone call to be made by prisoners on the first night in Reception, if available, or else in the first night location, in line with paragraph 2.42 of PSI 07/2015 – Early Days in Custody”, and requires Governors to make local arrangements to facilitate this. I acknowledge that the policy does not cover what to do when contact cannot be made on the first night, but it is clearly within the spirit of the policy that this exception should continue to apply until at least one successful call has been facilitated. I would expect Governors to make sure that this occurs, and we will make this clear in the policy when it is next revised. I have been assured by the Governor of HMP Lewes that there is now a specific checklist in use for reception and first night processes which includes ensuring that an initial phone call is given to all new arrivals before they are located onto a residential wing. The checklist includes a space to record the reasons why an action has not been completed and what will be done to rectify it. If a prisoner is unable to make their initial phone call or if the call is missed or unanswered, another phone call is facilitated the following day. Your second concern is about the process for logging and handling incoming calls to the central switchboard from family members with concerns about a prisoner’s safety and/or requesting a welfare check. Whilst there is an existing requirement in our Strengthening Family Ties Policy Framework for prisons to have such a system, I regret to say that many prisons have found this hard to deliver consistently in practice. In order to rectify this from 2020-22 we funded the charity Pact (through our innovations grant competition) to work with a number of pilot prisons to develop a toolkit of guidance and resources to support consistent and effective family engagement in safety processes, including recording, responding to and acting on safer custody concerns. Electronic logging of safer custody concerns was piloted in three prisons, and the more robust recording process produced significant improvements in recording and an increase in the number and proportion of calls from families that are returned. In light of this we are providing additional funding to Pact in 2023-24 and working with them to roll out the processes developed during the pilot to all prisons in England and Wales by March 2024. This includes the electronic logging of calls. Pact will be providing on site support to eight (geographically dispersed) prisons and the Group Safety Leads from the relevant and neighbouring prison groups will attend these prisons alongside Pact staff and participate in the upskilling sessions that they offer using the toolkit developed during the pilot, so that they are equipped to share the learning and to support the prisons in their groups that will not be receiving direct support from Pact. HMP Lewes will be one of the prisons receiving on site support from Pact – this is scheduled for December 2023. In the meantime, the prison have informed Operational Support Grade (OSG) staff that all calls received from family members, friends and members of the public regarding the welfare of a prisoner must be recorded within the Comms log and the information must be passed to the duty Orderly Officer or the night Orderly Officer immediately so that a welfare check can be carried out. There should always be an OSG working in the Comms room, however, in case of unforeseen circumstances, a notice to all staff has also been published setting out the actions staff must take when a call is received regarding the welfare of a prisoner. 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 Prisons
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