Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0299, written 21 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 | 21 Jun 2023 |
|---|---|
| Reference | 2023-0299 |
| Deceased | Matthew Harris |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Suicide (from 2015) · State Custody 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 THIS REPORT IS BEING SENT TO: 1) , Chief Constable, Dyfed-Powys Police. 1 CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire. 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 [the details below are fictional] On 1 June2022 I commenced an investigation and opened an inquest into the death of Matthew David Harris. The investigation concluded at the end of the inquest on 20 June 2023. The conclusion of the inquest was that Mr. Harris died as the result of suicide. 4 CIRCUMSTANCES OF THE DEATH In answer to the questions “when, where and how did Mr. Harris come by his death?”, the jury recorded as follows: “On 27.5.22 Matthew David Harris was found in his cell at HMP Long Lartin having suspended himself . As a result of his injuries he died on 29.5.22 at the Alexandra Hospital, Redditch. Matthew David Harris had a background of mental health and substance misuse issues.” Mr. Harris had been arrested on 13.5.22 by Dyfed-Powys Police on suspicion of murder, and was subsequently charged and remanded into custody at HMP Swansea on 16.5.22. 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. – (1) Following his arrest, and before he was interviewed about the alleged offence of murder, Mr. Harris was assessed by a consultant forensic psychiatrist, concluded that Mr. Harris was fit to be detained and fit to be interviewed, he did note possible symptoms of Post Traumatic Stress Disorder, likely due to some trauma in Mr. Harris’ background, possible symptoms of a personality disorder, and “potentially a psychotic process, with potential underlying delusional beliefs”; . Although 1 (2) During his police interview on 14.5.22, when describing his movements before the alleged murder had taken place, Mr. Harris told officers he had , intending to jump off in order to take his own life, but had decided against it because “I thought no, I’ve got to reveal all this first”; (3) Despite the fact that these comments revealed very recent suicidal ideation on Mr. Harris’ part, no mention of them appears to have been made in any of the following documents: (a) The Person Escort Record ( PER ) and Suicide and Self-Harm ( SASH ) Warning forms which accompanied Mr. Harris from police custody at Haverfordwest Police Station to Haverfordwest Magistrates’ Court on 16.5.22; (b) The PER and SASH Warning forms which accompanied Mr. Harris from Haverfordwest Magistrates’ Court to HMP Swansea later that same day. (4) Although I was quite satisfied that the omission of these comments from the above documents made no difference to the sad outcome in this case, I am concerned that the failure by Dyfed-Powys Police officers to realise that such comments ought to be included on a PER and SASH Warning form, if repeated in future, may lead to a person in custody’s risk of suicide and/or self-harm, being either underestimated, or ignored completely. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Constable of Dyfed-Powys 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 16 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: (a) Deighton Pierce Glynn solicitors ( acting for Mr. Harris’ family ); (b) Government Legal Department ( acting for HM Prison & Probation Service ); (c) Practice Plus Group; (d) Midlands Partnership NHS Foundation Trust; (e) Swansea Bay University Health Board; (f) HM Chief Inspector of Prisons; (g) Independent Advisory Panel on Deaths in Custody. I am also under a duty to send the Chief Coroner a copy of your response. 2 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 21 June 2023 David REID HM Senior Coroner for Worcestershire 3
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.
Mr. D D W Reid
H.M Senior Coroner
Coroner’s Court
Martins Way
Stourport-on-Severn
Worcestershire
DY138UN
Dear Sir,
Re: Matthew David Harris
Date: 8th August 2023
I would like to acknowledge receipt of your Regulation 28 report to prevent future deaths, prepared
following the conclusion of your investigation and inquest in relation to Mr. Matthew David Harris
on 20th June 2023.
I am cognisant of your finding that Mr. Harris died as a result of suicide.
In light of the fact that you have expressed an opinion that action should be taken to prevent future
deaths, I have caused a review to be undertaken.
As a result of this review, action has both been identified and implemented via my Head of
Custody Services, Chief Inspector
.
It is clear that on 14th May 2022 when Mr Harris was interviewed by my officers whilst detained at
Haverfordwest Police Station, he disclosed his recent suicidal ideation whereby prior to the murder
taking place he had intended to take his own life
I am mindful that the aforementioned information was not contained within the Person Escort
Record (PER) and Suicide and Self-Harm (SASH) Warning forms, both of which accompanied Mr
Harris to Haverfordwest Magistrates Court on 16th May 2022 and thereafter with him to HMP
Swansea later that same day.
I have noted that you are satisfied that the omission of information regarding Mr Harris’ recent
suicidal ideation from the aforementioned documents made no difference to the very sad outcome
in this case.
That said, I agree that learning can and should be derived from this omission, learning and action
that should assist in minimizing the risk of suicide / self-harm amongst those in custody.
To confirm, on 1st August 2023 via my Head of Custody Services, all staff involved in
investigations and those responsible for the care of detainees whilst in police custody have been
informed, in an anonymized manner of the nature of the omission in this case.
Custody Officers have been instructed to specifically ask interviewing officers whether they have
any information that is relevant to the ongoing duty of risk assessment; information needed to best
manage the welfare of the detainee.
Further, investigators have been reminded of their duty to inform the custody officer of any
information disclosed to them that should be considered as part of ongoing risk management.
Thank you for bringing this to my attention.
Yours faithfully
Chief Constable
Dyfed-Powys Police
Director General Operations
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London
SW1H 9AJ
16 August 2023
Mr David Reid
HM Senior Coroner for Worcestershire
HM Coroner’s Office
Worcestershire Coroner’s Court
Worcestershire
DY13 8UN
Dear Mr Reid,
Thank you for your Regulation 28 report of 21 June 2023, addressed to the Governor of
HMP Swansea and the Director General Chief Executive of HM Prison and Probation
Service. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS)
as Director General of Operations.
I know that you will share a copy of this response with Mr Harris’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.
You have raised some concerns following evidence heard at the inquest, regarding the
management of the Assessment, Care in Custody and Teamwork (ACCT) process at HMP
Swansea and the impact this has on supporting individuals at risk of self-harm and suicide.
Thank you for bringing your concern to my attention.
HMP Swansea have reviewed the management of the ACCT process and introduced a
thorough ACCT assurance procedure to ensure there is consistency and effective
completion of all ACCT documents. A dedicated safer custody officer now conducts a
comprehensive review of all open ACCT documents to ensure they are completed in line
with national policy. A number of additional checks are included in this process, with a
random sample also conducted by custodial managers and the senior management team.
This ensures that any inconsistencies or issues are addressed almost immediately.
The findings from the assurance checks are now discussed at safety custody meetings to
identify common themes and inform improvements, and are included on the prison duty
Governor Reports, which are sent daily to all HMP Swansea staff. Further to this, Governor
Orders and Notices to Staff are published on a bi-monthly basis to stress the importance of
effective ACCT case management.
Further ACCT training is currently being rolled out to all ACCT case managers at HMP
Swansea, which highlights the importance of consistency in case management, information
sharing, and record keeping. We are committed to ensuring ACCT management remains a
key focus of our work and so training in this area will be continuous.
Thank you again for bringing your concerns to my attention. I trust that this response
provides assurance that action is being taken to address this matter.
Director General Operations
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