Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0034, written 17 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jan 2024 |
|---|---|
| Reference | 2024-0034 |
| Deceased | Kane Boyce |
| Coroner | Laurinda Bower |
| Coroner area | Nottingham and Nottinghamshire |
| Category | State Custody related deaths · Alcohol, drug and medication 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1. Sodexo (via their General Counsel) 2. His Majesty’s Prison and Probation Service, The Rt Hon Edward Argar MP 1 CORONER I am Miss Laurinda Bower, HM Area Coroner, for the coroner area of Nottingham City and Nottinghamshire 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 Kane Christopher Boyce died by ligature asphyxiation on 3 October 2021, at HMP Lowdham Grange, Nottinghamshire, where he was detained as a serving prisoner. A coronial inquest into his death was opened on 23 November 2021. An inquest was resumed before a jury on 6 November 2023, concluding on 22 November 2023. 4 CIRCUMSTANCES OF DEATH The following represents the findings of fact returned by the jury: Kane Christopher Boyce (aged 41) was discovered inside his locked cell at 0150 on 3rd October 2021 with a ligature around his neck. Emergency first aid was provided by wing officers and healthcare prior to the arrival of paramedics. Kane could not be resuscitated, and he was declared deceased at 0223 on 3rd October 2021. His death occurred sometime between the hours of 0013 and 0150 on 3rd October 2021, a period of time he was not subject to observations. Kane was under the influence of alcohol at the time of his death. Kane obtained the alcohol from an unknown source during the day of 2nd October 2021, which was consumed throughout the evening in celebrations of this recent birthday. The level of alcohol found in his body has caused significant impact on Kane’s judgement and mood. Kane was prescribed an anti-depressant, which was not present in his toxicology report, which indicates that Kane had not taken his prescribed medication for at least five days prior to his death. Both of these factors combined contributed to this death. The jury returned a narrative conclusion determining that - Kane’s death was not intentional He was intoxicated with alcohol which contributed to his death Three separate members of staff suspected Kane to be acting under the influence of alcohol when they spoke to him at 23.14 hours, 23.29 hours and 00.08 hours, respectively. Those staff all failed to adequately share information about Kane’s intoxication with colleagues. Regulation 28 – After Inquest Document Template Updated 30/07/2021 They further failed to open an ‘under the influence log’ contrary to the local prison policy. This failing contributed to the circumstances of his death because the opening of a log would have necessitated a medical review with regular monitoring of his condition by healthcare over the following hours. Instead of following the policy on the night of his death, staff isolated the electricity supply to the sockets inside his cell in order to prevent him from playing loud music. The decision to isolate his cell from the electricity supply was not an authorised and approved prison action, and it was not supported by training or guidance for staff. Staff failed to consider Kane’s level of risk of harm or his wellbeing when isolating the electricity supply. Staff actively ignored Kane’s cell bell for long periods of time. The action of ignoring cell bells was not an authorised and approved prison action, and staff were not supported to do so with training and guidance. Again, staff failed to consider how this might affect his level of risk of harm or his wellbeing. The above failings more than minimally contributed to his death. 5 CORONER’S CONCERNS During the course of the inquest I heard evidence of 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: (brief summary of matters of concern) The following matters of concern are directed to Sodexo for response - It is important to note that at the time of Kane’s death, the prison was managed by Serco Ltd under a contract awarded by HMPPS. Since Kane’s death, the contract for managing the prison has been awarded to Sodexo. Sodexo were invited to submit learning evidence to the court, if such existed, but instead said they would respond to any prevention of future death report I felt was necessary. A number of the prison staff involved in Kane’s care in October 2021 continue to work at the prison and were unaware of local policy in relation to the matters below as of present times. Having received no formal evidence of any changes made at HMP Lowdham Grange, and staff having failed to report any evidence of changes, I highlight the following concerns - 1. Ignoring Cell Bells I heard evidence that staff were engaging in the deliberate ignoring of prisoner cell bells. I have seen no local policy which either prohibits such activity, or, if such activity is permitted, supports staff to make risk-based considerations about how and when to ignore cell bells. I observe that deliberately ignoring cell bells appears to be a wholly dangerous practice as the cell bell is the only method of communication between prisoner and staff during periods of lock up, including night state. The practice appears to be all the more dangerous when one considers some staff suspected Kane to be in a state of heightened emotion and acting under the influence of alcohol. 2. Isolating power to cells As above, I have seen no policy which supports the isolation of power to cells including who has the power to make such a decision, how long the power should be isolated for, and whether staff are required to consider any risk factors when determining whether to isolate power to the cell. 3. Failure to follow the local Under the Influence Policy Three members of staff suspected Kane was under the influence of something in the hours before his death, yet none opened an under the influence log or sought any medical advice Regulation 28 – After Inquest Document Template Updated 30/07/2021 about how frequently to check on him, what signs of deterioration to look out for, and when to seek further assistance. 4. Lack of understanding of Prison Service Instruction 64/2011, and possible discord between local policy and the PSI A number of prison officers believed Kane’s birthday was incapable of amounting to a “key date or anniversary” for the purposes of PSI 64/2011. It seems to me to be common sense that a birthday, being the anniversary of one’s birth, could amount to a potential trigger date for heightened emotions which considering a prisoner’s risk of self harm and suicide. That is not to say it would be so for each and every prisoner, but perhaps something to be cognisant of when dealing with an emotional and intoxicated prisoner. I have seen no evidence that this is covered in Sodexo’s training for staff on the ACCT process, if indeed any series of training exists. A number of prison officers gave evidence that an ACCT was not necessary because Kane had not said to anyone that he was going to harm himself (either fatally or otherwise). Serco’s Safer Prison Operating Policy (August 2022) is confusing on this point and seems to suggest at paragraph 3.4 that staff should only open an ACCT when a statement of self-harm has been verbalised. This is not consistent with the PSI. Sodexo have not offered for scrutiny any local policy, guidance or training material on the threshold for opening an ACCT, but even if such exists, it appears some staff continue to labour under the misapprehension that a prisoner must say they are thinking of harming themselves before an ACCT can be opened. 5. A failure to implement learning from the investigations that follow deaths in custody Many of the staff giving evidence explained that they had not read the PPO report, nor were they aware of the issues identified by the PPO prior to giving evidence at the inquest. I have seen no evidence of the systems in place at HMP Lowdham Grange to seek to learn from deaths in custody at the earliest opportunity. The following matters of concern are addressed to The Minister for Prisons and Probation, HMPPS – 6. Poor Quality Early Learning Review process, November 2021 While it is recognised that the ELR process is designed to capture information at a very early stage of the investigation, it is nevertheless an important tool in seeking to identify safety issues that should be addressed swiftly in order to prevent future deaths. The central issue in this case was obvious from the outset, as recorded in various intelligence reports submitted by staff on the night of the death, namely, a number of members of staff suspected Kane to be under the influence of alcohol yet failed to take the necessary steps to seek to safeguard against harm. On page 4 of the ELR it is concluded that “all procedures were followed” and there were no local or national recommendations for learning lessons. It is difficult to rationalise this conclusion against the evidence available even at the earliest stages of the investigation. The author was clearly aware that staff had considered Kane to be under the influence of alcohol (see page 1) and should have been aware that no Under the Influence Log existed. The author simply notes that “the policy has been reviewed”. There is no explanation as to why the policy wasn’t followed. Was the policy unclear in its requirements? Was there an absence of staff training on the policy? Of great concern to me is the fact that staff giving evidence at the inquest still seemed to fail to grasp the significance of intoxication as a risk factor for self-harm. My concerns extend beyond the quality of the report, but also to the accuracy of the same. The report is written in such a way as to create the impression that the author interviewed key members of staff. Comments are attributed to staff at particular points in time, yet all Regulation 28 – After Inquest Document Template Updated 30/07/2021 prison staff witnesses denied ever having been interviewed as part of the ELR process. It is unclear exactly what methodology the author has used during the investigation. I am concerned that the quality of the investigation has led to missed opportunities to have identified these issues at the outset. 7. A Lack of Candour – both organisationally and individually I would be very interested to understand how the duty of candour applies to the prison service and those individuals within the employ of the service (whether employed directly or through a private provider, as in this case). There is a statutory duty of candour applicable to healthcare organisations and professionals, as well as a more recent agreement by the College of Policing for members to adhere to a Code of Candour. In practise, candour creates a culture of being open and honest with all stakeholders by accepting when things go wrong, taking remedial steps as soon as practicable, and thus reducing the risk of events repeating themselves. In the context of a death, candour from the outset is essential in order to support the bereaved family. The position adopted by Serco in this inquest, as it has in other inquests, could be said to represent the very opposite of candour. Having heard evidence supplied on Oath by their own staff members that there were multiple failures to open an under the influence log (evidence which was not contested) the organisation nevertheless required the Jury to return a finding on this issue, and each and every issue, instead of a factual finding being presented to the jury as agreed by all Interested Persons. The inquest is not an adversarial process, there is no burden of proof. The Interested Persons are under a duty to assist the investigative process in an open and honest manner by identifying those issues that genuinely require determination by the jury, and those on which there is agreement. Sadly, in my extensive experience of conducting Article 2 inquests locally, this is not an isolated example of the uncomfortable position adopted by the prison service in failing to put forward sensible and reasonable factual admissions of shortcomings. I am concerned by the apparent absence of a culture of candour supporting those staff who work within the prison service. Many of the staff members giving evidence explained that the inquest was the first time it had been suggested to them that they had not adhered to policy. In the intervening period of over two years between Kane’s death and the inquest, no-one at the prison had asked key staff to reflect on the care they provided to Kane that night and consider areas of learning. Again, this is not a position unique to this inquest, and is of great concern in the context of a rising number of self-inflicted prisoner deaths at HMP Lowdham Grange since Kane’s tragic death in 2021. I would be grateful if your response could address what steps have been, or are being taken, to ensure that candour is applied throughout the death in custody process. 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 13 March 2024. 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 I have sent a copy of my report to the Chief Coroner and to the following: • • The Interested Persons INQUEST Charity who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner. 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: 17 January 2024 Miss Laurinda Bower HM Area Coroner Nottingham City and Nottinghamshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email: 7 March 2025 Laurinda Bower HM Area Coroner Nottingham City and Nottinghamshire The Council House Market Square Nottingham NG1 2DT Dear Miss Bower, Thank you for your Regulation 28 report of 17 January 2024 addressed to the Minister of State for Prisons, Parole and Probation following the inquest into the death of Kane Boyce at HMP Lowdham Grange on 3 October 2021. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Prisons. I know that you will share a copy of this response with the family of Mr Boyce, 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 a concern about the quality of the Early Learning Review (ELR) in this case. As you point out, ELRs conducted by Group Safety Leads (GSLs) are a potentially very helpful way of quickly identifying key learning from deaths, enabling prompt action to address any issues arising from them. The practice of undertaking them was initiated by the GSLs, and they do not form part of our policy on responding to a death in custody as set out in chapter 12 of PSI 64/2011. Perhaps as a result we have been aware of considerable variation in practice, and I acknowledge that the resulting reports have not always been as useful as they could be. In 2021 the National Safety Team issued guidance and a standard template to assist those conducting the reviews and to bring greater consistency to the reports, which improved the overall quality. Being implemented during the COVID-19 pandemic meant our ability to deliver face-to-face training was limited and as such we have continued to work to improve the quality of ELRs, including holding a workshop with GSLs in July 2022 at which the National Safety Team shared the results of a review of a sample of reports and provided feedback designed to improve practice in the conduct of the reviews and the writing of the reports. We continue to monitor the quality of ELRs and to share feedback on them with GSLs. We are currently working on a new policy framework on the follow-up to deaths in custody (replacing PSI 64/2011) and intend to use that to mandate the early learning review process, and to make clear that it is the responsibility of the Prison Group Director to satisfy themselves of the quality of the ELR before signing the report off. Alongside the new policy framework, we will issue a revised standard template and a refreshed guidance document. We also held a workshop with GSLs in April 2024 to offer additional upskilling, including input from our psychology team. This was followed up with an offer of individual feedback to GSLs to help them to build their skills and confidence in this area. I would like to assure you that HMPPS’ approach to investigations following a death in custody is to ensure that all learning is identified and used to improve our practices and understand where things have gone wrong in our management of prisoners. It is therefore vital that staff are encouraged to be honest about their actions and accept where they may not have met the standards required of them. Internal investigations are often commissioned following a death in custody, with the findings of these made available to both the Coroner and Prisons & Probation Ombudsman to assist in their investigations. I take our responsibility to assist the Coroner to properly explore the circumstances of any death extremely seriously, and our staff are reminded by senior leaders and our legal team of the need to be completely transparent in their statements and live evidence, and we will always seek to made admissions where appropriate. It is my expectation that providers in the contracted estate take the same approach, both organisationally and individually to adhere to the same policy frameworks, mandated instruction and legal requirements as a public sector site. 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
Miss Laurinda Bower HM Area Coroner, for the coroner area of Nottingham City and Nottinghamshire The Council House Old Market Square Nottingham NG1 2DT 13 March 2024 Dear Miss Bower Inquest into the death of Kane Christopher Boyce Thank you for your Regulation 28 Report, issued following the inquest into the death of Mr Kane Christopher Boyce at HMP Lowdham Grange. At the time of Mr Boyce’s death the prison was operated by Serco. Sodexo were not involved in the substantive inquest proceedings, but did appear for the conclusion in the hope of providing you, and the family of Mr Boyce, with assurance that we are committed to the learnings from Mr Boyce’s death. Sodexo Limited took over the operational management of HMP Lowdham Grange on 16 February 2023. We took the opportunity to welcome your thoughts on issues at HMP Lowdham Grange with reference to the evidence you had heard regarding the death of Mr Boyce and expressed our content that you should issue any such PFD report that you considered appropriate from the evidence that you had heard. It is in that vein that, we wrote to the HM Senior Coroner for Nottinghamshire, in October 2021, noting that Sodexo would be taking over the operation of the prison and explaining that we were very keen to hear any issues that might have been noted, or areas of concern, so that we could be mindful of these as operations commenced. You will be aware that the Ministry of Justice (MOJ) has stepped in to HMP Lowdham Grange for an interim period, in doing so the prison is now under the operational control of a MOJ Governor. Sodexo continues to work closely with the MOJ and remains the employer of the staff and responsible for overall delivery of our contract with the MOJ. A copy of this letter has been shared with the MOJ and, as you will see from the below, they are committed, alongside us, to implement learnings to address your concerns. You raised the following concerns in respect of HMP Lowdham Grange: 1. Ignoring Cell Bells 2. Isolating power to cells 3. Failure to follow the local Under the Influence Policy 4. Lack of understanding of Prison Service Instruction 64/2011, and possible discord between local policy and the PSI 5. A failure to implement learning from the investigations that follow deaths in custody Sodexo Legal Services, One Southampton Row - London - WC1B 5HA Tel.: 0161 872 4781 Sodexo Limited – No 842846 – England – Registered Office – One Southampton Row – London – WC1B 5HA www.sodexo.com Each of the above is listed below, alongside Sodexo’s response to each concern. 1. Ignoring Cell Bells Your Regulation 28 Report notes that there was evidence that staff were engaging in the deliberate ignoring of prisoner cell bells. You noted that you had not seen a local policy which either prohibits such activity, or, if such activity is permitted, supports staff to make risk-based considerations about how and when to ignore cell bells. Sodexo agrees that wilfully ignoring cell bells is a wholly dangerous practice and one that is not permitted by Sodexo in any circumstances. Sodexo requires all cell bells at HMP Lowdham Grange to be answered within 5 minutes. The HMPPS Governor has issued a Governor’s Order to address this, a copy of which is attached as Appendix 1. Sodexo has produced a policy in reference to this, and when the operational management of the prison returns to Sodexo Appendix 2 will apply. 2. Isolating power to cells The Governor’s Order, already attached as Appendix 1, makes clear that power should not be isolated to a cell unless approved by the Duty Director (which would be either Director or Deputy Director within Sodexo) on the grounds of health and safety. The circumstances where power might be isolated would be for example if a prisoner was actively damaging the cell fabric, including the electrics – power would be isolated for a short period whilst arrangements were made to relocate the prisoner. 3. Failure to follow the local Under the Influence Policy Sodexo have concerns about the practices of the staff that transferred to Sodexo with HMP Lowdham Grange. These include failures of staff to conduct observations and follow the Under the Influence Policy. This is part of an ongoing culture change that we are trying to address but one that takes time and has to date involved changes to Senior Managers and Officers at the prison. The Governor’s Order, Appendix 1, makes it clear that staff are to open an under the influence log and inform healthcare if they suspect a prisoner is under the influence of drugs or alcohol. 4. Lack of understanding of Prison Service Instruction 64/2011, and possible discord between local policy and the PSI When the HMP Lowdham Grange members of staff transferred to Sodexo, Serco provided a list of officers and dates that they had undertaken training, or when that training expired. They did not provide copies of the training or details of the content, despite requests. Sodexo follow the national Prison Service Instruction 64/2011 which provides the framework underpinning any local policy. Sodexo deliver to staff the national training package issued by HMPPS for ACCT, version 6 and ACCT Assessor. To enable this Sodexo facilitators complete the national ACCT Train the Trainer course delivered by HMPPS facilitators. Relevant Sodexo staff also receive the national training package delivered directly by HMPPS facilitators on ACCT Case Coordinators. The MOJ have confirmed that all managers, including the Senior Leadership Team, are to undergo the national ACCT training as a matter of urgency, this will include ACCT Assessor training and case manager training. When the operational management of the prison returns to Sodexo all staff will undergo ACCT refresher training, if not done before. 5. A failure to implement learning from the investigations that follow deaths in custody Sodexo is committed to continuous learning and improvement. Following a death in custody at a Sodexo prison (whilst under Sodexo operational management) an Early Learning Review is required – this should be completed within 7 days. The Early Learning Review notes areas of good practice and recommendations, the Director is expected to ensure that any recommendations are complied with – alongside any recommendations made by the PPO. The level of Sodexo investigation required following the Early Learning Review will depend on the circumstances, for example a natural causes death in a hospital may not require anything further however a suicide will result in a substantial fact find investigation, on some occasions by a senior manager of another Sodexo prison. The Director is responsible for ensuring that any recommendations and learning are implemented. The above processes only apply when the prison is under Sodexo’s operational management. We know that you will share a copy of this response with Mr Boyce’s family, and we would like to express our sincere condolences for their loss. The implementation of learning from this sad death is a priority. Yours sincerely Sodexo Limited
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