Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0102, written 22 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Feb 2024 |
|---|---|
| Reference | 2024-0102 |
| Deceased | Matthew Price |
| Coroner | John Hobson |
| Coroner area | West Yorkshire (Eastern) |
| Category | Suicide (from 2015) · State Custody related deaths |
| 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) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1 2 3 4 THIS REPORT IS BEING SENT TO: 1. The Rt Hon Alex Chalk KC MP, Minister of Justice. CORONER I am John Hobson, Assistant Coroner, for the Coroner area of West Yorkshire (Eastern) District. 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. INVESTIGATION and INQUEST On 30th June 2023 I commenced an investigation into the death of Matthew Gregory Price. An inquest was concluded on 30 January 2024. The conclusion of the Inquest was that Mr Price died of multiple injuries, with a short-form conclusion of suicide being recorded. CIRCUMSTANCES OF THE DEATH Matthew Gregory Price was aged 48. He was convicted of a s.18 assault by wounding in 2010 when he was aged 35 and has been subject to an Indeterminate Sentence for Public Protection (‘IPP’). He served a term of imprisonment before being released back into the community. Whilst IPP sentences were abolished in 2012, Mr Price remained subject to his sentence which was imposed in 2010. At the time of his death, Mr Price had engaged legal support in order to make an application for review of his sentence which was at an early stage. Since 2022, a review is initiated at the ten-year mark and yearly thereafter, if appropriate. Mr Price’s first ten- year review was due to take place in November 2023. At the conclusion of the inquest, I recorded the following facts. ‘On the evening of 16 June 2023 Matthew Gregory Price was struck by a train travelling from Leeds to Manchester at Cottingley Railway Station, Cottingley Drive, Cottingley . He suffered multiple injuries and his death was confirmed by paramedics at 2149 hours. Matthew’s mental well-being had been adversely affected over a significant period of time by the continuing impact of serving an Indeterminate Sentence for Public Protection (IPP). He was especially anxious that seeking help in respect of his mental health could impact negatively when making an application to discharge the sentence further to its imposition in 2010. It is apparent from a text message sent just prior to his death that Matthew intended to take his own life’ 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. It was apparent from the evidence that I heard and read at the inquest that there are serious concerns about the welfare of individuals who remain subject to IPP sentences. For example, the Independent Monitoring Boards (‘IMB’) completed a report with key findings entitled ‘The impact of IPP sentences on prisoners’ wellbeing’ in May 2023. This report was written following the rejection by the government of the recent Justice Select 1 Committee’s recommendation for a re-sentencing exercise to take place for anyone serving an IPP sentence. Whilst the key findings of the IMB report are focused upon the impact upon serving prisoners and the prevention of recall, I was deeply concerned about the evidence I heard in relation to the clear impact that the on-going IPP sentence had had on Mr Price. He had served a three year tariff and at the time of his death he had been released back into the community for nearly ten years Mr Price was anxious about the ever-present potential for recall to prison. Furthermore, he had conveyed in communications to others that he felt that seeking help with his mental health by way of support and medication might count against him when seeking to be successful in discharging the IPP. Whilst Mr Price was engaged with legal support in navigating the review process, the on-going impact of uncertainty of being on an IPP sentence was clearly apparent. As a consequence of undertaking Mr Price’s inquest, the on-going wellbeing of those serving IPP sentences, be that in prison estate or in the community, is a matter of concern to me as a Coroner. The Ministry of Justice is fully apprised of the IPP context and whilst matters have been raised by the IMB I am concerned that specific focus upon the welfare of individuals living in the community should be appraised by those who may be able to take appropriate steps to further support an evidently vulnerable section of society, 6 7 8 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that as Minister of Justice you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18th April 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to Mr Price’s family. I have also sent a copy to Mr Price’s solicitor who provided evidence to the inquest. 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. 22 February 2024 9 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 of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Mr John Hobson, Assistant Coroner for the Area of West Yorkshire (Eastern) By e-mail to Dear Mr Hobson, 23rd May 2024 Inquest Touching the Death of Matthew Gregory Price Thank you for your Regulation 28 report of 22nd February 2024 following the Inquest into the death of Matthew Gregory Price. You kindly extended the time for the issue of this response to the 23rd May 2024. I am responding on behalf of the Rt Hon Alex Chalk KC MP, Minister of Justice. I know that you will share a copy of this response with Mr. Price’s family, and I would like to take this opportunity to express my condolences for their loss. You raised the following concerns - There are serious concerns about the welfare of individuals who remain subject to IPP sentence with specific focus on those living in the community and appropriate steps should be taken to further support an evidently vulnerable section of society The MoJ/HMPPS now provides Introductory Suicide Prevention Training for probation staff developed in collaboration with the Zero Suicide Alliance (ZSA) which has been available to all probation staff since September 2023. Over 1700 staff have now completed this training. Further comprehensive suicide prevention training is in the training development pipeline. A 7 minute briefing on suicide prevention has been developed for Probation staff and is available on EQUiP, an electronic database of guidance and process maps. This draws attention to those serving IPP sentences. Under the current engagement model between Health/ Justice/ NHS / Social Care teams the MOJ are working closely with other government departments to ensure prison leavers, including those serving IPP sentences, can access healthcare, drug treatment and support with securing employment and stable accommodation. The MoJ/HMPPS has a current Suicide Prevention Action Plan within which one of the identified goals is to provide staff with the necessary knowledge, skills, and resources to support good quality suicide prevention practice. As part of the refreshed probation learner offer, Probation Practitioners who manage IPP cases are provided with dedicated learning products aimed at increasing their knowledge and skills around trauma aware/person centred practice, as well as opportunities to practice motivational interviewing approaches. The Skills for Effective Engagement Development and Supervision (second generation) (SEEDS2) practitioner package, which is required learning for all Probation Practitioners who have been in post for at least six months, has motivational interviewing/relational practice as the core principle. The probation learner offer will be evaluated and reviewed in September 2024. As part of an IPP Action Plan, HMPPS is drawing together a holistic staff IPP guide and series of practitioner briefing events which will promote HMPPS operational staff awareness of the IPP sentence and its impact on those subject to it. This guide and series of events will include a focus on recall. Alongside the learning and development/training being provided to Probation staff regarding suicide prevention, you may be aware that there are also proposed changes being taken forward in the Victims and Prisoners Bill which relate specifically to IPP sentences. These proposed new measures will 1. Reduce the qualifying period which triggers the duty of the Secretary of State to refer an IPP licence to the Parole Board for termination from ten years to three years; 2. Include a clear statutory presumption that the IPP licence will be terminated by the Parole Board at the end of the three-year qualifying period; 3. Introduce a provision that will automatically terminate the IPP licence two years after the three-year qualifying period, in cases where the Parole Board has not terminated the licence; and 4. Introduce a power to amend the qualifying period by Statutory Instrument 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. Yours sincerely, Director General of Operations
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