Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0227, written 3 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jul 2023 |
|---|---|
| Reference | 2023-0227 |
| Deceased | Liam Bentley |
| Coroner | Patricia Harding |
| Coroner area | Mid Kent and Medway |
| Category | State Custody related deaths · 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. MINISTER OF STATE FOR PRISONS AND PROBATION 1 CORONER I am Patricia Harding, senior coroner, for the coroner area of Mid Kent & Medway 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 13th June 2022 I commenced an investigation into the death of Liam Ryan Wayne Bentley. The investigation concluded at the end of the inquest on 29th June 2023. The conclusion of the inquest was Liam Bentley took his own life ( ) but his intention in doing so was unclear. The failure to provide adequate physiological support through SOS and/or a psychologist possibly contributed to the death. Other issues which were deemed to be relevant to the circumstances of the death but could not possibly contribute to the death were as follows. 1. Failure to open an ACCT on or after 16th April. 2. Failure to instigate a care plan 3. Inadequate response to missed medication from 16th April onwards. 4. The Management of the self seclusion plan was inadequate, and failures to implement agreed actions from CSIP and SIM meetings. 5. Ineffective communication between the prison and the health care provider. 6. Staff shortages and gaps in training. 4 CIRCUMSTANCES OF THE DEATH Liam Bentley was transferred to HMP Swaleside on 25th March 2022. He was a serving prisoner with a sentence expiry in 2024. He had ADHD and ASD for which he was medicated with mirtazapine administered by healthcare and at the time of his death atomoxetine, held in possession. He had 19 previous ACCTs for self harm and an attempt at suspension whilst serving his sentence at other establishments. Following his transfer he informed prison staff that he was in fear of other prisoners and wanted a move to another wing. He caused a superficial cut to his hand and said that he wanted to kill himself before anyone else did. An ACCT was not opened, the evidence being that officers after further speaking to him did not regard this as a self harm issue, the focus being to engineer a wing move. He was moved to a different wing but continued to express concerns about prisoners on the new wing. A self seclusion document was opened, a local policy closely aligned to the ACCT process aimed at reintegrating the prisoner to the regime was started but was not managed in accordance with the policy with assessments and reviews being done weeks after they should have been and no management plan were not put in place. Required daily interactions were sometimes done, sometimes not, referrals to psychology and SOS were either not made having been identified as necessary through the self seclusion, CSIP and SIM processes or made and not actioned 1 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 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. – (1) There was evidence from prison staff from which it was concluded by the jury that the safety of deceased was compromised as a result in staff shortages (2) The current complement of Band 2 Operational Support Group staff is 71% this is predicted to further reduce to 54%, the current complement of Band 3 Prison Officers is 68% this is predicted to further reduce to 46%. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29th August 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 Family of Liam Bentley, HMPPS, HMP Swaleside. I have also sent it to HMPPO and Oxleas NHS Foundation Trust 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. 9 3rd July 2023 Patricia Harding Senior Coroner Mid Kent & Medway 2
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 Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Patricia Harding Senior Coroner for Mid Kent & Medway Cantium House Sandling Road Maidstone ME14 1XD 10 October 2023 Dear Ms Harding Thank you for your Regulation 28 report of 3 July 2023 addressed to the Minister of State for Prisons and Probation following the inquest into the death of Liam Bentley at HMP Swaleside on 6 June 2022. I am responding on behalf of HMPPS as Director General of Operations. I know that you will share a copy of this response with the family of Mr Bentley, 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 concerns around staffing levels and safety at HMP Swaleside. Thank you for bringing your concerns to my attention. Firstly, I thought it might be helpful to clarify the figures on staffing levels that you have referred to in your report. HMPPS carry out a lot of work to understand reasonable worst case and likely staffing scenarios for prisons, and look to ensure that action is taken to intervene where the recruitment and retention positions look challenging. This includes deploying staff from other sites to supplement the staffing group directly employed at the prison. These figures do not represent the current or future staffing position at HMP Swaleside, in part due to the actions undertaken locally and nationally to improve recruitment and retention. Ensuring that prisons are sufficiently resourced is fundamental to ensuring that we are delivering quality outcomes for offenders. We continue to monitor staffing levels at HMP Swaleside and, as in other establishments, look to provide short-term tactical support where possible. Where establishments feel that their staffing levels will affect stability or regime, there are a number of ways they can maximise the use of their own resource and seek support from other establishments in the short term, through processes managed nationally at agency level. These include overtime payments and support via detached duty staff from other prisons. In addition to short-term support, we are seeking to improve the staffing position at HMP Swaleside through a range of interventions across pay, recruitment and retention. This includes the introduction of the new colleague mentor scheme which provides support to those who are new to the prison service to ensure that they feel supported throughout their early careers. HMP Swaleside is supported by recruitment interventions including Advance into Justice which supports Armed Forces veterans and their spouses into frontline roles; Prison Officer ‘Futures’ where new recruits are recruited directly to establishments with a strong track record of recruitment but, for the first 23 months, they will be expected to be deployed at a named establishment elsewhere to temporarily reduce their vacancy position; and our National First Time Officer scheme which recruits officers nationally sending them to a prison which has difficulty recruiting, with additional financial support. We also use locally targeted PR activity, including a new recruitment ‘landing page’ specific to the prison, where prospective staff can view videos of frontline officers from Swaleside to understand what it is like to work there. The 2023/24 pay award will deliver a pay increase of £2,000 for our lowest paid staff, Band 2 Operational Support Grades, as well as a 7% pay increase for Band 3-5 prison officers. HMP Swaleside is also in receipt of a market supplement, which means Band 3 officers working at the prison receive more pay in order to attract and retain more staff. We hope that this significant investment, which builds on progress from last year’s pay award, will have a positive impact on recruitment and retention. 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
See every Prevention of Future Deaths report matching State Custody related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.