Prevention of Future Deaths reports · 2024

Matthew Price

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 report22 Feb 2024
Reference2024-0102
DeceasedMatthew Price
CoronerJohn Hobson
Coroner areaWest Yorkshire (Eastern)
CategorySuicide (from 2015) · State Custody related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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 

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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’ 

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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, 

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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                        

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2

Responses

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.

Response from Hmpps (PDF)
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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