Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0269, written 20 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 | 20 Jul 2023 |
|---|---|
| Reference | 2023-0269 |
| Deceased | Stephen Weatherley |
| Coroner | Jenny Goldring |
| Coroner area | London Inner (South) |
| Category | Alcohol, drug and medication related deaths · State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , The Director at HMP Thameside, Griffin Manor Way, London, SW28 0FJ. , Director General Chief Executive HM Prison and Probation Service (HMPPS), 102 Petty France, London, SW1H 9AJ. Mr Alex Chalk KC MP, Lord Chancellor and Secretary of State for Justice, Ministry of Justice, 102 Petty France, London SW1H 9AJ.1 Colonnade, Canary Wharf, London, E14 4PU. , HM Chief Inspector of Prisons, HM Inspectorate of Prisons, 3rd Floor, 10 South 1 CORONER I am Jenny Goldring assistant coroner, London Inner South jurisdiction. 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 1. The death of Stephen Weatherley (“SW”) was reported to the coroner by HMP Thameside on 24th February 2018. 2. A forensic post-mortem was conducted on 27th February 2018 and the report was completed on 9th July 2018.The medical cause of death of SW was 1a: Combined toxic effects of cocaine and methadone. 3. On 16th March 2018, an Inquest was opened into the death of SW and an Article 2 Inquest was heard between 9th May 2023 and 22nd May 2023 with a jury. The jury concluded with a narrative conclusion and a short-form conclusion of drug-related death. I have considered Prevention of Future Death (“PFD”) evidence and submissions on 12th June 2023 and additional written evidence/submissions between 26th June 2023 and 5th July 2023. 4. 4 CIRCUMSTANCES OF THE DEATH 1. SW died from the toxic effects of cocaine and methadone whilst detained at HMP Thameside. 2. He was a known drug dependant individual receiving methadone therapy. 3. On 7th October 2017, during a visit he was seen to attempt to plug something down his trousers. SW was searched and no item was found. He was moved to the care and separation unit (“CSU”) for monitoring and his visitor was banned for 3 months from all visits. An adjudication hearing was held and there was no finding against him due to lack of evidence. 4. SW was then held on closed visits until a new decision was made on 31st January 2018 to change his status to open visits. The same visitor who attended on 7th October 2017 was allowed on open visits, contrary to local guidance. 5. On 23rd February 2018, staff monitored SW's visit and reacted to a call over the radio (by the CCTV operator), for a suspected pass, restraining SW and taking him away to a room to be searched. His visitors were taken to separate rooms to be questioned and not searched. 6. The CCTV footage was reviewed at this point and no pass was seen by staff. SW was searched and nothing was found by officers. SW was returned to his wing. The nurse was informed and given no indication that SW had received any contraband. 1 Please direct to the relevant MOJ/HMPPS person/body with oversight of the contract under which Serco runs HMP Thameside. 7. Various calls were made by SW that evening. At the time they were not listened to by prison officers. Later review of the calls confirmed reference to swallowing an item. SW had swallowed a package. 8. On the morning of 24th February 2018, the cellmate found SW on the floor with blood coming from his mouth and activated the cell bell at 0705. It was answered but not responded to in person. A second cell bell call was made at 0723. It was answered by staff and another member of staff was sent to the call where SW was seen lying on the floor experiencing a seizure. 9. A nurse attended the cell at 0726, and an ambulance was called. After a delay in entering the prison, the ambulance reached SW at 0741. CPR was administered and SW was confirmed dead at approximately 0847. 10. The jury found that the conveyance by SW’s visitor of a list A article into the prison and passing it to SW was a material contribution to his death. 11. The decision to allow this visitor (who had been banned on 7th October 2017) an open visit on the 23rd February 2018 was a material contribution to SW’s death. The decision was inappropriate due to various factors including insufficient record keeping and information sharing, inadequate scrutiny of the decision made and failure to follow policy. 12. The decision by prison staff to not to monitor SW possibly made a material contribution to his death. There was insufficient investigation after the visit and a lack of implementation of precautionary measures. The omission of searching the visitors post-visit and a defective decision-making pathway possibly made a material contribution to SW’s death. 5 CORONER’S CONCERNS During the Inquest, the evidence revealed matters giving rise to concern. A number of these have been addressed and do not require a PFD report. For the record, I have been informed that an upgrade of the cell bell system is agreed and quotes have been requested. 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. – • Data recording and retention in HMP Thameside /oversight by the Ministry of Justice (“MOJ”). • Absence of a written policy at HMP Thameside if there is a suspected drug swallow. Data recording and retention in HMP Thameside/oversight by MOJ 1. Key documents around decision making by Serco officers in respect of open/closed visits for SW were lost. 2. Record keeping of key events on 23rd and 24th February 2018 was not properly completed by Serco officers on the central system for recording, operated by the MOJ (“PNOMIS”). 3. There were only 3 entries on SW’s PNOMIS record in the 5 months he was at HMP Thameside. 4. The PPO investigator encountered delays in obtaining documents, unclear and incomplete records from HMP Thameside. The decision making around closed visits/reviews was requested by the PPO in September 2018 and had not been provided at the time the PPO reported in April 2019, which pre-dated the electronic migration of data in October 2020 (see below). 5. Solicitors representing HMP Thameside informed me on 30 March 2023 that the prison was unable to adduce the 2018 versions of the local standard operating procedures in place at the time of SW’s death (i.e re visits procedures) due to a large IT migration which took place around 18 months prior (October 2020), which resulted in the loss of some historical data saved on their systems. I subsequently requested the underlying decision making around closed visits/review (as had the PPO before me) and was informed that these documents were no longer available, also lost in the electronic migration. I was then informed (during the Inquest), that material may have been lost due to officers storing it on local desktop computers and not uploading it to the main system. 8. Having expressed concerns about record-keeping and data retention, I heard PFD 6. 7. evidence on 12th June 2023 about a limited internal audit of PNOMIS which revealed concerns over 15% of the records reviewed. I heard evidence that contract managers oversee the contract between the MOJ and Serco, reporting monthly on contract delivery 9. indicators. They do not conduct specific checks on PNOMIS record keeping/audits of the same. I also heard evidence on 12th June 2023 that there remain two systems for record keeping, the Serco system, CMS and the national MOJ system, PNOMIS. CMS requires a layer of officer input (uploading and/or printing off) to ensure retention and distribution. A notice to staff dated 23rd June 2023 reminded them to upload material to CMS. 10. A witness statement from the director of HMP Thameside dated 26th June 2023 further explained the contractual relationship between the MOJ and Serco including the 28 contract delivery indicators. There is also a contractual requirement to ensure compliance with Prison Service Instructions (PSIs) which include PSI 04/2018 which relates to records, information management and retention policy. 11. In this witness statement, the director stated that he had instructed the Serco Assurance Team (independent of the prison team) to conduct a widespread audit of the PNOMIS and Death in Custody files, which will be completed by September 2023. Whilst I am reassured that an independent audit is being conducted, the results are not currently available. SW died in 2018 and the audit was not initiated until June 2023. 12. I accept that there have been improvements. However, given the extent and impact of the deficiencies outlined above, I remain concerned as to whether systems (for both record keeping and retention) have improved sufficiently since 2018. 13. I am also concerned as to the level of oversight and monitoring by the MOJ (having subcontracted to Serco) of recording and retention of data, given that key data was lost, key records were not maintained and the PPO was not provided with documents requested. 14. If key documents are not available/ incidents are not recorded contemporaneously, then the PPO and the Inquest process is frustrated. It is more difficult to identify deficiencies and prevent future deaths. Further, if communications are not recorded, there is a risk that relevant factors are not considered when officers are making potentially life-impacting decisions. Absence of a written policy at HMP Thameside if there is a suspected drug swallow. 15. In 2018, there was no written policy as to what should occur where there may have been a drugs swallow but it had not been seen immediately by staff or on CCTV. That remains the case. 16. In SW’s case, the body scanner had not been installed in 2018 and following a search of SW and review of the CCTV he was returned to the wing (and not taken CSU or healthcare). The jury found that there was insufficient investigation after the visit and a lack of implementation of precautionary measures. 17. I was informed by HMP Thameside on 12th June 2023, that in a similar situation the prisoner would now be scanned using the body scanner. If the prisoner had concealed an item in a bodily orifice he would be taken to CSU. If he had swallowed an item, he would be taken to Healthcare. I was told this is standard practice but is not written down. Further, if a prisoner refused a scan, he would be taken to CSU. The management of the prisoner in CSU would be the subject of an algorithm deployed by Healthcare, which then produced guidance as to monitoring. There would be liaison between Healthcare and CSU to ensure the prisoner was appropriately monitored. 18. At present the system relies upon good communications/decision making between healthcare and discipline staff and individual judgement. 19. I remain concerned as to the absence of written guidance for officers and the risk that if they are not aware of the above “informal” guidance, a prisoner may not be taken to the correct location (CSU or Healthcare) and/or there may not be appropriate monitoring. I appreciate that each situation is fact specific and drafting written guidance may be difficult. 6 ACTION SHOULD BE TAKEN Action should be taken by HMP Thameside and the Ministry of Justice2: 1. Given the deficiencies in record keeping/data retention highlighted during the Inquest, consideration should be given by HMP Thameside and the Ministry of Justice (who oversee the contract) as to whether record keeping and data retention at HMP Thameside has improved sufficiently since 2018. 2 As above, please ensure that this report is directed to the appropriate body/person within the MOJ/HMPPS. 2. The Ministry of Justice should consider their oversight of record keeping/data retention at HMP Thameside (to ensure both compliance and ongoing improvement).They should consider how is this to be monitored and if necessary enforced. 3. Consideration by HMP Thameside as to the feasibility of a written policy to provide guidance to officers when there has been a suspected drug swallow. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 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 (TV Edwards) for the family (DWF) for Serco (Capsticks) for Oxleas (Womble Bond Dickinson) for We are With you. , Chair Independent Advisory Panel on Deaths in Custody, 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 25th August 2023
4 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.
HM INSPECTORATE OF PRISONS
3rd floor
10 South Colonnade
Canary Wharf
London E14 4PU
Date : 26th July 2023
HM Chief Inspector of Prisons
Assistant Coroner
Southwark Coroners Court
1 Tennis Street
London
SE1 1YD
Dear Ms Goldring
Thank you for sending His Majesty’s Inspectorate of Prisons (HMI Prisons) a copy of your
Regulation 28 report following the death of Mr Steven Weatherley at HMP Thameside.
Your correspondence was received by our office on 24 July 2023.
In response, it is important that I outline that the purpose of HM Inspectorate of Prisons
is to ensure the regular independent inspection of places of detention, report on
conditions and treatment and highlight concerns to the relevant authorities with the aim
of improving outcomes for those detained. As such our remit is distinct from the role of
HM Prison and Probation Service and so my response can only address issues related to
the inspection process.
Inspections are carried out against published inspection criteria known as Expectations
and as an independent inspectorate those criteria are set by me. We collate these
Expectations against what we term our four tests of a ‘healthy’ prison, which include
safety, respect, purposeful activity and rehabilitation and release planning. Issues related
to self-harm are addressed under our safety test. All our reports are published and placed
in the public domain.
We last carried out a full inspection of HMP Thameside in November 2021, following this
inspection, we published written reports which include our concerns and the
recommendations we made at the time to the prison.
We inspect adult prisons for men at least once every 5 years and often more frequently.
As part of our preparation for each inspection we liaise closely with the Prisons and
Probation Ombudsman, and have in place arrangements to share information. Nearly all
of our inspections are unannounced and based on an on-going risk assessment. The
information you have been able to provide us will, of course, feature significantly in our
assessment of risk at HMP Thameside.
26/07/23-
www.justiceinspectorates.gov.uk/hmiprisons
-
I hope that you find the information we have provided useful. If you require anything
further, we would be happy to assist.
Yours sincerely
26/07/23-
www.justiceinspectorates.gov.uk/hmiprisons
-
HM INSPECTORATE OF PRISONS
3rd floor
10 South Colonnade
Canary Wharf
London E14 4PU
Date : 26th July 2023
HM Chief Inspector of Prisons
Assistant Coroner
Southwark Coroners Court
1 Tennis Street
London
SE1 1YD
Dear Ms Goldring
Thank you for sending His Majesty’s Inspectorate of Prisons (HMI Prisons) a copy of your
Regulation 28 report following the death of Mr Steven Weatherley at HMP Thameside.
Your correspondence was received by our office on 24 July 2023.
In response, it is important that I outline that the purpose of HM Inspectorate of Prisons
is to ensure the regular independent inspection of places of detention, report on
conditions and treatment and highlight concerns to the relevant authorities with the aim
of improving outcomes for those detained. As such our remit is distinct from the role of
HM Prison and Probation Service and so my response can only address issues related to
the inspection process.
Inspections are carried out against published inspection criteria known as Expectations
and as an independent inspectorate those criteria are set by me. We collate these
Expectations against what we term our four tests of a ‘healthy’ prison, which include
safety, respect, purposeful activity and rehabilitation and release planning. Issues related
to self-harm are addressed under our safety test. All our reports are published and placed
in the public domain.
We last carried out a full inspection of HMP Thameside in November 2021, following this
inspection, we published written reports which include our concerns and the
recommendations we made at the time to the prison.
We inspect adult prisons for men at least once every 5 years and often more frequently.
As part of our preparation for each inspection we liaise closely with the Prisons and
Probation Ombudsman, and have in place arrangements to share information. Nearly all
of our inspections are unannounced and based on an on-going risk assessment. The
information you have been able to provide us will, of course, feature significantly in our
assessment of risk at HMP Thameside.
26/07/23-
www.justiceinspectorates.gov.uk/hmiprisons
-
I hope that you find the information we have provided useful. If you require anything
further, we would be happy to assist.
Yours sincerely
26/07/23-
www.justiceinspectorates.gov.uk/hmiprisons
-
Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 28 November 2023 Ms Jenny Goldring HM Assistant Coroner Southwark Coroners Court 1 Tennis Street London SE1 1YD Dear Ms Goldring, Thank you for your Regulation 28 report of 20 July 2023 addressed to the Secretary of State for Justice and the Director General Chief Executive of His Majesty’s Prison and Probation Service (HMPPS). I am responding on behalf of HMPPS as Director General of Operations. I apologise for the late return of this response. I know that you will share a copy of this response with Mr Weatherley’s family, and I would first 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 expressed a concern regarding record keeping and data retention at HMP Thameside and have asked for assurance of the Ministry of Justice’s oversight of this process. I can confirm that I have received a copy of the response from the Director at HMP Thameside which sets out the policies that the prison must adhere to and the contract requirements. To further assist, I can confirm that the contract has several delivery indicators which measure the performance of all aspects of custodial delivery. The prison’s performance is reviewed each month and during quarterly contract reviews. All aspects of the custodial contract are monitored through provider submissions and compliance testing. Each month the provider, Serco, submit evidence that they have complied with all contract delivery indicators (CDIs) and compliance tests are carried out on a monthly basis to test different aspects of the contract which are scored on a RAG (red, amber, green) rating scale for monitoring and improvement purposes. There is a specific CDI which relates to the management of records and data retention. If the provider falls short of the required standards outlined in policy then contractual action would be taken. There is a clear escalation route to ensure that performance is monitored, improvements are seen, and standards are raised to an acceptable level. Following deaths in custody, prisons are required to follow their local death in custody contingency plan, which includes retaining relevant evidence and documentation for the Prisons and Probation Ombudsman’s investigation and the Coroner’s inquest. The contract management team at HMP Thameside monitor the provider’s management of death in custody cases to ensure that any issues or areas of concern are identified and addressed. Thank you again for bringing your concern to my attention. I trust that this response provides assurance that there is a sufficient oversight process in place to monitor the contract at HMP Thameside. Yours sincerely, Director General of Operations
Contract Director
Serco UK & Europe
HMP Thameside
Griffin Manor Way
Thamesmead
London
SE28 0FJ
www.serco.com
8th September
2023
Official-Sensitive
FAO: HM Assistant Coroner Goldring
London Inner South Coroner's Court
1 Tennis Street
London
SE1 1YD
By Email
Dear Ms Goldring
Inquest touching upon the death of Mr Stephen Weatherley
We refer to the Regulation 28 Report dated 20 July 2023 (the "Report") which followed the
Inquest, which took place from 9 May – 22 May 2023 into the unfortunate death of Mr
Stephen Weatherley who died at HMP Thameside (the "Prison") on 24 February 2018. For
the purpose of this response, we will refer to Mr Weatherley as ("SW").
We note that the Report has been copied to Director General Chief Executive HM Prison
and Probation Service (HMPPS), Lord Chancellor and Secretary of State for Justice, Ministry
of Justice, HM Chief Inspector of Prisons, HM Inspectorate of Prisons and Chair of the
Independent Panel on Deaths in Custody. We provide the following response on behalf of
the Prison, and we would like to take the opportunity to address you on each of your
concerns in turn, for ease of reference.
The report raised two particulars concerns as follows.
Concern One
(1) Data recording and retention in HMP Thameside / oversight by the Ministry of
Justice ("MOJ")
("Concern One")
Retention of Data
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Firstly, in relation to data retention following a Death in Custody ("DIC"), Assistant Director
("AD")
provided evidence at the Inquest that he now has autonomy of this
process and that there is now a system in place whereby he has set up MS Teams folders
was
which contain all the relevant information, in accordance national PSI's.
candid in accepting that he could not explain why documents weren’t provided to the Prison
and Probation Ombudsman ("PPO") back in 2018 (before he was in post) as the relevant
staff members were no longer employed by Serco. However in any circumstance since, he
has personally provided the PPO with the information required to further their investigations.
It was offered by
during the inquest that he could show you the files in order to
satisfy you that the Prison were sufficiently engaging with the process and retaining the
correct information. You understandably indicated that without knowing the specific facts of
the case, this might be difficult to assess.
explained in evidence that he was aware of an IT migration which took place in
2020, requiring officers to upload any documents retained locally onto a SharePoint. As you
outline, he offered this as a possible explanation as to the absence of the documents which
were now lost. Whilst this migration did unfortunately mean a lot of information was lost, the
positive implication is that now the IT infrastructure, as explained by
, is much
better. It allows much wider access to PNOMIS and means he is able to access relevant
documents when requests are made.
Since then, evidence was provided in the form of a statement from me (
)
on behalf of the Prison, which identified an audit from our Quality Assurance ("QA") team
was obliged to complete. It was also submitted that one of the Contract
that
Delivery Indicators ("CDI's") that the Prison is required to deliver under their contract with the
Ministry of Justice ("MOJ") means they have to comply with relevant PSI's, which includes
those specific to document retention and what should happen after a DIC.
It was indicated by me that I attend a Quarterly Contract Review Meeting with the MOJ
controllers and we discuss findings from the PPO investigations. Nonetheless, an
independent audit of the retention of documents on the DIC cases was instructed from the
Assurance Team (part of the Serco Enterprise Risk Management team) and reporting to
UK&I General Counsel of Serco. It was confirmed that this is independent to the Prison and
arrangements for this are underway, with an expected completion date of September 2023.
The difficulty with the case of SW was that it had been delayed for a number of years (to
some extent due to the criminal liability for SW's visitors) so the management of the DIC's
had long since improved and the Prison had no cause for concern in relation to the DIC
information retention since my appointment three years ago.
In relation to CMS, there is some reliance on the staff to upload documents. However, again,
as previously advised the QA team conduct daily audits on incidents and notify AD's of any
deficiencies, which are then rectified. We are confident that the CMS system is updated and
that there are plentiful safeguards in place such as the QA team and the management team
to ensure documents are properly uploaded and retained.
Data Recording
Secondly, in relation to the recording of information on PNOMIS
provided
evidence that in short, the PNOMIS system is now much more regularly utilized and
updated.
conceded that in SW's case, the entries contained with the PNOMIS
file were insufficient and he candidly accepted that it fell below his expected standards
during the Inquest and at the PFD hearing on 12 June 2023, which the Prison do not in any
way dispute.
A small audit was completed by
in short order to assist you with your concerns
before 12 June 2023. However, as provided in my statement dated 26 June 2023, the Prison
have instructed the same Serco independent audit team to conduct an independent review
of a wider selection of PNOMIS files. Again, arrangement are in place to have this completed
by September 2023 and we understand that our legal team, DWF LLP, offered to share the
results of the same with you on our behalf. It is understood that this offer was made in email
correspondence on 05 July 2023.
We understand that the MOJ may wish to address you in relation to the latter half of your
Concern One. However, for the sake of completeness, a copy this letter and my earlier
statement has been provided to them.
Concern Two
(2) Absence of a written policy at HMP Thameside if there is a suspected drug
swallow ("Concern Two")
In terms of Concern Two, there is a written Serco Custodial Security Strategy ("SCSS")
dated July 2021 which outlines when a prisoner can be put through the bodyscanner and it
incorporates the national policy 'Use of X-ray Body Scanners (Adult Male Prisons)' dated 18
May 2022 and reissued 3 October 20221 which states:
Any prisoner can be body scanned upon receipt of intelligence into the
prison. This may be prior to a prisoner’s arrival at the prison or at any time whilst
they are present within the prison. No prisoner can be forcibly scanned.
This is clear written guidance that any prisoner at any time whilst they are in the prison can
be taken to the bodyscanner on grounds of intelligence. It does however state that they
cannot be forcibly scanned. No prisoner in any establishment can be legally forced to be
scanned using the bodyscanner. This reflects the evidence of
One of the grounds upon which a prisoner can be searched through the bodyscanner is
below:
Reasonable suspicion during or following a visit that the individual is likely to be
internally concealing contraband.
In the instance where a scan is conducted, the same SCSS sets out that:
.
Ensure that the body scan is recorded on NOMIS. The date, dosage and
justification (either intelligence or reasonable suspicion) of each scan must be
recorded on NOMIS. This must be recorded as soon as practical after the scan is
conducted. The NOMIS record must also record whether or not any suspected
contraband was detected by the scan.
This written policy contains clear guidance, which addresses some of your concern in
relation to Concern One.
Finally, you heard evidence from
during the PFD hearing on 12 June 2023 that if
a prisoner refuses to be scanned, they will be sanctioned and sent to the CSU under prison
discipline rules and that as part of this process, their risk to self should be considered. There
1https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/111559
6/x-ray-body-scanners-use-pf.pdf
is a dual function to this, in that it protects the prisoner themselves but also reduces
channels for prisoners to distribute any items into the main prison population.
This is further supported by the SCSS, which outlines:
If a prisoner refuses to be scanned, or intentionally moves to distort the
image, it may be appropriate to charge the prisoner with an offence against prison
discipline under Rule 51(22) Prison Rules 1999/Rule 55(25) Young Offender
(see PSI 05/2018 Prisoner Discipline Procedures
Institution Rules 2000
(Adjudications) for further detail), or have their incentive level downgraded and in
accordance with the Prison’s Incentive Scheme. If staff believe that this is the
case, they should consider whether it is necessary to manage the prisoner, in
terms of risk to self, as if they do have an internally concealed item (as below).
The management of Security at any prison is, as you can imagine, a lengthy framework. The
SCSS itself consists of 494 pages and underwrites the functions of all staff obligations. In
relation to the bodyscanner and searching, all of the above falls under 'Function 3' of the
witness statement dated 8th June 2023 that notices
SCSS. You will recall from
were sent to staff outlining their obligations to make themselves familiar with the various
functions, which included function 3. Staff are also trained in using the bodyscanner before
using it (as is stipulated in the national framework) and therefore the information within this
function is known to them.
The National Policy further underpins that:
5.101 If the prisoner refuses or is unable to safely remove or pass a suspected item
the prison must consider the risks presented by that prisoner to themselves and/or
others. In all cases the prison must consider the location and observation
requirements of the prisoner. This could include use of segregation and/or ACCT, if
applicable, locating the prisoner in healthcare, or sending the prisoner for outside
medical intervention. This decision should be made in conjunction with the advice
from healthcare.
It has been recommended to the Serco board that wording to this effect and including
additional wording (underlined) where they simply refuse to go through the scanner and not
just refuse to remove an item, is now incorporated within the SCSS and re-shared with staff.
Please see recommended wording below:
5.101 If the prisoner refuses or is unable to safely remove or pass a suspected item
(or simply refuses to be scanned at all) the prison must consider the risks presented
by that prisoner to themselves and/or others. In all cases the prison must consider
the location and observation requirements of the prisoner. This could include use of
segregation and/or ACCT, if applicable, locating the prisoner in healthcare, or sending
the prisoner for outside medical intervention. This decision should be made in
conjunction with the advice from healthcare.
Whilst this was not previously written in the SCSS (but was in national policy), you will recall
that when a prisoner goes through body scanner, if they fail
the oral evidence of
it then they go to CFU or healthcare. 'If plugged or secreted they go to CFU and if
swallowed then they go to healthcare.' He also gave evidence that the Prison now have a
'good relationship with healthcare' and seek their advice in such circumstances. Even in
the case where prisoners are taken to CSU, it is still healthcare who conduct the initial health
assessment and complete the algorithm, which dictates how often a prisoner should be
monitored. You will recall from his evidence that the use of the bodyscanner generally has
revolutionised the way in which prisons are able to detect items as you can either prove or
was unable to
disprove the existence of a secreted item very easily. Although
point to 'where it was written down' in the hearing, he did indicate the same premise for
decision making that is highlighted above from the national policy. We are confident that
trained staff at the Prison, in conjunction with healthcare, would ensure any prisoner at risk
of having secreted an item is properly managed.
In real circumstances as at today's date, any suspicion which leads to a request for a
prisoner to go through a bodyscanner which is then subsequently met with a refusal to
partake in the scan would only raise staff suspicions further. A manager would check the
CCTV and they would consult healthcare with the relevant facts/suspicions (as was
submitted in evidence during the Inquest and at the PFD hearing on 12 June 2023). More
specifically, if a member of healthcare is told by Prison staff that they have either seen a
prisoner put their hand to their mouth or it has been seen on CCTV (or in any other very
limited circumstance) they could properly suspect a 'swallow' then healthcare staff are
afforded the opportunity to make a risk assessment based on their proper clinical judgement.
In
evidence, he submitted that in his quite proper experience, the distinction
between a suspected 'swallow' and 'plug' would mean the difference between CSU and
impatient unit in practicable terms.
As you have quite rightly outlined in your Report, each case is fact specific and the above
guidance reflects the same. To some extent, prison policy has to have some ambiguity to
account for a variety of circumstances and is reliant on the judgement of prison staff,
together with medically qualified clinicians. For the avoidance of doubt, any prisoner refusing
to go through the bodyscanner (which would in all circumstances reveal a swallow) would be
relocated to either CSU or healthcare, which requires the input of senior management and
healthcare. A prisoner could only be moved to either location with the sign off of an AD That
AD will, only with the input of professional medical opinion, make a decision on location of
that prisoner. We can confirm that we will be sharing the learnings of this Inquest and indeed
the contents of the Report with the senior management team within the Prison and preface
with advice that where there is a suspected 'swallow' and absence of a positive bodyscanner
result, they should re-locate to healthcare.
The difficulty with SW's case in 2018 was that staff restrained him, found nothing during the
search and could not see a pass on CCTV (which was reviewed again by management), no
'hand to mouth' was revealed on CCTV (giving no reason to suspect a swallow) and SW and
his visitors protested their innocence. In today's Prison, SW would be asked to go through
the bodyscanner. If he had, the package would have been revealed and immediate steps
taken to manage his safety. Alternately, he could have refused which would have raised
concern (and cast doubt on his earlier protestations of innocence) and resulted in a breach
of prison rules, re-allocating him to CSU for monitoring.
However, with the introduction of the bodyscanner, the development of security strategies
(including more trained intelligence analysts) and the implementation of a highly skilled
senior team, we are confident that the Prison is far more able than in 2018 to identify the
need for earlier interventions in such tragic circumstances.
We take all Death's in Custody incredibly seriously. We reflect upon areas of concern and
make every effort to prevent similar situations occurring in the establishment.
I hope this response provides you with sufficient assurance that the matters of concern that
you have identified in relation to the death of Mr Weatherley are being fully addressed.
Yours Sincerely.
Director, HMP Thameside
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