Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0341, written 19 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Sep 2023 |
|---|---|
| Reference | 2023-0341 |
| Deceased | Stewart Stanley |
| Coroner | Philip Spinney |
| Coroner area | Exeter and Greater Devon |
| 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT DATED 19 SEPTEMBER 2023 IS BEING SENT TO:
Governor Exeter Prison
***by email only***
1 CORONER
I am Philip SPINNEY, HM Senior Coroner, for the coroner area of Exeter
and Greater Devon.
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 15 July 2020 an investigation was commenced into the death of
Stewart Stanley. The investigation concluded at the end of the inquest
held on 17 -27 July 2023. The conclusion of the inquest was Suicide in
addition the Jury answered a series of questions raised by me.
In summary, the Jury concluded that Mr Stanley’s death was probably
caused or contributed to by a failure to follow the processes resulting in
the staff best qualified to appreciate Stewart’s risk to himself being
excluded from the decision to remove him from constant watch. In the
addition the Jury concluded that the multi-disciplinary processes in place
were adequate however they were not fully complied with in this case.
4 CIRCUMSTANCES OF THE DEATH
On 23 June 2020 Mr Stanley was remanded in custody to HMP Exeter.
On the night of 9 to 10 July, Mr Stanley’s cellmate found him
seemingly trying to hang himself. He alerted
prison staff, who started Prison Service suicide and self-harm prevention
procedures (known as ACCT). The staff placed Mr Stanley under
constant supervision and moved him to a special cell that allowed an
officer to observe him continuously. On 11 July, after a case review it was
decided that constant supervision should end and directed that Mr
Stanley should now be observed at least once every half an hour during
the evening. At around 1.20am on 12 July, the night patrol officer, found
1
Mr Stanley hanging. She called for staff assistance and, when it arrived,
they opened the cell, removed the ligature and began chest
compressions. Paramedics arrived and took Mr Stanley to hospital, where
he died on 14 July.
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) The evidence revealed that there was an inconsistent approach
taken by staff when conducting and recording observations on
prisoners subject to the Prison Service suicide and self-harm
prevention procedures (known as ACCT).
(2) The evidence also revealed that some Officers had a different
interpretation of the requirements of set out in PSI 64/2011 in
respect of the timing of observations.
(3) The evidence also revealed that precise times of such
observations were not routinely being recorded accurately.
(4) During the evidence it became apparent that a prison officer
worked 23 hours out of 24, he was asked if this was normal and he
replied, “yes, to make the regime work.”
6 ACTION SHOULD BE TAKEN
(1) Consideration should be given to reviewing the process of
conducting and recording ACCT observations to ensure
accuracy and compliance with relevant policy and guidance.
(2) Consideration should be given to reviewing staffing levels,
retention, and recruitment to ensure the efficient and safe
running of the prison.
In my opinion action should be taken to prevent future deaths and I
believe you and 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 16th November 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
2
why no action is proposed.
8 COPIES and PUBLICATION
I have sent a copy of my report to:
The solicitors for the family of the deceased
Government Legal
Practice Plus Group
Devon Partnership Trust
The Chief Coroner
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 SIGNED:
Mr Philip C Spinney
HM Senior Coroner
Exeter and Greater Devon
3
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 of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 10 November 2023 Mr Philip Spinney HM Senior Coroner County Hall Topsham Road Exeter EX2 4QD Dear Mr Spinney Thank you for your Regulation 28 report of 19 September 2023 addressed to the Governor of HMP Exeter. 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 Stanley’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 regarding the management of the Assessment, Care in Custody and Teamwork (ACCT) process and staffing levels, recruitment and retention at HMP Exeter. Thank you for bringing your concern to my attention. HMP Exeter have reviewed the management of the ACCT process and have introduced an assurance procedure to ensure there is consistency and effective completion of all ACCT documents including observations. All ACCT are now allocated to a supervising officer who is responsible for conducting daily checks to ensure all set observations for the previous 24 hours have been completed. Any discrepancies are highlighted with the safety team for prompt action. Since February 2023, the Prison Performance Support Programme (PPSP) have provided funding for 12 months for two Band 4 ACCT safety ‘Floorwalkers’ who are responsible for conducting regular upskilling sessions which include the need for accurate completion of observations. Further to this, ACCT V6 observation posters have been displayed in all wing offices and guides have been produced for staff. With regards to your second concern, we remain committed to ensuring prisons are sufficiently resourced to deliver quality outcomes and ensure staff and prisoner safety, as well as improving our regime offering. Staffing has been an ongoing challenge at HMP Exeter, but from June 2020 to June 2023, the total number of operational staff increased by 12% (from 199 to 222), with Band 3-5 officers specifically increasing by 7% (from 165 to 176). Nationally, we continue to monitor staffing levels across the estate, and when staffing levels affect stability or the regime, there are a number of ways establishments can maximise the use of their own resources and seek support from other establishments to address staffing shortfalls. HMP Exeter have previously received support with additional marketing activity to bolster the recruitment pipeline. Further to this, we have introduced a retention toolkit to help Governors identify the drivers of attrition in their prisons. Following the Urgent Notification received by the prison in November 2022, additional action was taken to address concerns relating to leadership and staffing, this included a review of staff profiles and the core day regime. HMP Exeter remains classed as a ‘standard plus’ site, which reflects its complexity. A business case to uplift managerial grades has been approved to attract and retain experienced managers, and therefore improve stability of the leadership team for the Governor, Deputy Governor and Head of Safety grades. More widely, there is ongoing work within HMPPS to examine the overall staffing model for Public sector prisons. The project aims to improve our analysis of resource allocation across the system and ensure that we have prioritized our staff resources to address key business. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address. Yours sincerely, Director General of Operations
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