Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0134, written 12 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Mar 2024 |
|---|---|
| Reference | 2024-0134 |
| Deceased | Giuseppe Tabone and Andrew Evans |
| Coroner | Michael Spencer |
| Coroner area | East Sussex |
| Category | Alcohol, drug and medication 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 HM Prison and Probation Service 1 CORONER I am Michael Spencer, Assistant Coroner for the coroner area of East Sussex. 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 01 July 2022, I commenced an investigation into the deaths of Giuseppe TABONE aged 58 and Andrew EVANS, aged 34, who both died on 28 June 2022 in HMP Lewes. The investigation concluded at the end of the joint inquest into their deaths on 26 February 2024. The conclusion of the inquest was that: Andrew Evans and Giuseppe Tabone died as a result of Misadventure by Drug Related Overdose. This was caused by a synthetic opioid namely isotonitazene. Due to the potency of the drug, 500 times more powerful than Morphine, it is likely they became unconscious very quickly and died. There were admitted failures by Prison staff to carry out roll checks at 19.30 and 20.45 on 27th June 2022. It is not possible to say whether had those checks been carried out their lives would have been saved. Isotonitazene had not been encountered in prison before therefore had the anit-drug Naloxone been administered it may not have been effective as a normal single dose is used but for isotonitazene multiple doses may be needed. 4 CIRCUMSTANCES OF THE DEATH Giuseppe and Andrew died from the intentional inhalation of isotonitazene at HMP Lewes. Clinical evidence of the onset of death is inconclusive but suggests it is likely that Giuseppe and Andrew fell unconscious shortly after inhaling the substance. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed 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) At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the Regulation 28 – After Inquest Document Template Updated 30/07/2021 control room and were not responding to prisoner’s cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training. I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state. The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning. There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check. Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members. I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out. There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out. 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 May 7, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Practice Plus Group The family of Giuseppe Tabone The family of Andrew Evans I have also sent it to HM Inspectorate of Prisons 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 and all interested persons who in my opinion should receive it. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 12/03/2024 Michael SPENCER Assistant Coroner for East Sussex Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 12 June 2024 Michael Spencer Unit 56 Innovation Centre Highfield Drive St Leonards on Sea East Sussex TN38 9UH Dear Mr Spencer, Thank you for your Regulation 28 report of 12 March 2024 addressed to HM Prisons and Probation Service (HMPPS) following the inquest into the deaths of Giuseppe Tabone and Andrew Evans at HMP Lewes on 28 June 2022. I am responding as Director General of Operations for HMPPS. I know that you will share a copy of this response with the families of Mr Tabone and Mr Evans, 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 concerns around staff completing roll checks and the measures in place to ensure that the required checks are being carried out. I am grateful to you for bringing your concerns to my attention. Roll checks are a fundamental part of ensuring the security and safety of those in our care. Whilst the primary purpose of roll checks is to ensure that all prisoners are accounted for, staff are required to take any necessary action if there are any immediate concerns for a prisoner’s welfare. All prisons are required to have a local security strategy in place which includes a local operating procedure (LOP) that covers what security checks need to be carried out by staff. These include roll checks and any other mandatory checks, such as ACCT observations. The duties and expectations of all staff are clearly communicated and staff receive training and shadowing before working on the wings. For OSGs who work alone during the night state, these duties include carrying out a roll check at the beginning and end of each shift which must be reported to the control room and signed for. The Governor of HMP Lewes has informed me that the prison’s LOP on roll checks was reviewed in August 2023 and clearly sets out the times that roll checks are required to be carried out and where staff must sign to confirm that the checks have been completed. The LOP provides guidance on checks during the week, on weekends and during the night state so that staff understand what their duties are at all times. I am also informed that the prison has published notices to staff highlighting the importance of carrying out roll checks in line with expectations. A notice to staff was issued in August 2023 which prompts staff to consider three points when carrying out roll checks: • Is the cell door secured? • Are the correct number of occupants in the cell? • Have you observed signs of life with all occupying the cell? Following the inquest into the deaths of Mr Tabone and Mr Evans, the prison is reviewing roll checks to ensure that processes are in line with new staffing profiles and regime planning which is currently being reviewed and updated. Once this work is complete, a new notice to staff will be issued setting out learning from the inquest around roll checks. There is a quality assurance process in place whereby the Orderly Officer (a Custodial Manager grade working during the night) or the Duty Governor carry out a check to satisfy themselves that the roll check has been completed and recorded. If roll checks are found to be incomplete, the member of staff is reminded of the importance of completing roll checks fully and warned that undertaking roll checks are part of their duties and that a failure to complete these may lead to disciplinary action being taken. I understand that evidence was given at the inquest on the assurance measures in place for roll checks at the prison but that you remain concerned that the measures are insufficient. Whilst I am also concerned to learn of instances where staff have not carried out their duties in line with clear expectations, we must be able to trust staff to carry out the required tasks that are fundamental to their role. HMP Lewes hold a daily briefing which provides an opportunity to update and remind staff of the duties to be carried out as well as to convey any other important information. Staff are aware that CCTV is in use around the establishment and that their actions may be scrutinised following an incident such as a death in custody. If staff are found to have failed to carry out the required tasks or when there is a question over their performance and ability there will be a thorough investigation to determine what has happened and to ensure that staff who fail to uphold the values of HMPPS by putting prisoner’s safety at risk are held to account through disciplinary procedures. Staff are aware that failure to carry out the duties entrusted to them will result in disciplinary action, and that, depending on the circumstances, the outcome may range from advice and guidance in order to support them to perform better, to dismissal from the service. As you are aware, in this case, the prison investigated and disciplined the staff members who failed to carry out the roll checks. It is important that staff understand the importance of their duties, and the consequences of not fulfilling them properly, so we will continue to ensure that appropriate action is taken where staff fail to meet expectations. I can confirm that HMP Lewes has planned further sessions of ‘bite size’ training on roll checks. The two members of staff who gave evidence that they had not received the training will be required to attend as a priority. Additionally, the prison has received support from the standards coaching team, a national resource, which consisted of a team of experienced prison staff shadowing officers at HMP Lewes to provide support and on-the- job training. The team covered roll checks as part of the support. 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 Operations, HMPPS
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