Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0169, written 27 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 | 27 Mar 2024 |
|---|---|
| Reference | 2024-0169 |
| Deceased | Francis Williams |
| Coroner | Nick Armstrong |
| Coroner area | West Sussex, Brighton and Hove |
| 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 2 1 CORONER I am Nick ARMSTRONG KC, Assistant Coroner for the coroner area of West Sussex, Brighton and Hove 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 03 February 2023 I commenced an investigation into the death of Francis Ian WILLIAMS aged 43. The investigation concluded at the end of the inquest on 05 March 2024. The conclusion of the inquest was that: Francis Williams was the subject of a sentence of imprisonment for public protection (“IPP”), imposed in 2006. He had always struggled with that sentence, believing that he would never be free of it. He had been released in 2009 and by 2018 had had the supervision element of the sentence removed. In 2020, however, and in part following problems experiencing during the Covid lockdown, supervision was reinstated and in March 2021 Francis was recalled to prison. Francis was re-released in April 2022 and initially seemed to be progressing well once again. In late 2022 and early 2023, however, Francis was struggling once more, and in particular, with alcohol. He had lost one set of specialist accommodation in November 2022. He then had a warning from the new one on 9 January 2023. On 27 January 2023 Francis was finally evicted from that accommodation after he had been drunk the night before and had behaved inappropriately including towards female staff. The probation service sought urgently to find alternative accommodation but without success. They started to take steps to recall him to prison. Francis realised that is what was likely to happen, and he told his probation officer he was going to kill himself call to police. On 28 January 2023, however, Francis was found by workmen in a tent in the sunken gardens in Bognor Regis. He had died of a heroin overdose. He was 43 years old. . She made a warning 4 CIRCUMSTANCES OF THE DEATH Francis Williams was the subject of a sentence of imprisonment for public protection (“IPP”), imposed in 2006. He had always struggled with that sentence, believing that he would never be free of it. He had been released in 2009 and by 2018 had had the supervision element of the sentence removed. In 2020, however, and in part following problems experiencing during the Covid lockdown, supervision was reinstated and in March 2021 Francis was recalled to prison. Francis was re-released in April 2022 and initially seemed to be progressing well once Regulation 28 – After Inquest Document Template Updated 30/07/2021 again. In late 2022 and early 2023, however, Francis was struggling once more, and in particular, with alcohol. He had lost one set of specialist accommodation in November 2022. He then had a warning from the new one on 9 January 2023. On 27 January 2023 Francis was finally evicted from that accommodation after he had been drunk the night before and had behaved inappropriately including towards female staff. The probation service sought urgently to find alternative accommodation but without success. They started to take steps to recall him to prison. Francis realised that is what was likely to happen, and he told his probation officer he was going to kill himself call to police. On 28 January 2023, however, Francis was found by workmen in a tent in the sunken gardens in Bognor Regis. He had died of a heroin overdose. He was 43 years old. . She made a warning 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) My investigation reveals two relevant concerns: That probation officers need to understand, and be constantly alert to, the risk of 1. suicide/self-harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it. 2. Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether. One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation. Mr Williams was then overtaken by lockdown and related matters in 2020, which pulled the rug on his business and other protective factors, and he then returned to supervision and ultimately recall to prison. Following release in 2022 he was still not referred, and even at the end of that year - which I note was now after the amendments to s.31A of the Crime (Sentences) Act 1997 and the introduction of an entitlement to automatic referral to the Parole Board for cancellation – no referral had been made. By then, of course, Mr Williams might have found cancellation much more difficult. However, it is noteworthy that even with those well publicised changes, which Mr Williams had heard about, his probation officer seemed to be struggling to find out how the process worked (entries in the probation records in December 2022 confirm). Again, the point is that there is a particular kind of despair among the IPP cohort. The main safeguard is the facility for getting off that, or at least giving these men hope that they may be able to get off it. Mr Williams and his probation officer were struggling to find out how to access even that limited (and automatic) safeguard. It was very shortly after that (within a month or so) that he took his life. The jury was clear that the fact of the IPP caused his state of mind and so caused his death. It seems to me that these two concerns at least give rise to a training need. There may be more. But I consider that action should be taken. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 22, 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 I have also sent it to The Chief Coroner 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. 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: 27/03/2024 Nick ARMSTRONG KC Assistant Coroner for West Sussex, Brighton and Hove 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
Mr. Nick ARMSTRONG KC,
Assistant Coroner for the coroner area of West Sussex, Brighton and Hove
24th May 2024
Dear Mr Armstrong,
Inquest Touching the Death of Francis Ian Williams
Thank you for your Regulation 28 Report of 27th March 2024 following the Inquest into the death
I am responding on behalf of the Rt Hon Alex Chalk KC MP, Minister of
of Francis Williams.
Justice and the Chief Probation Officer,
.
I know that you will share a copy of this response with Mr. Williams’ family, and I would like to
take this opportunity to express my condolences for their loss.
You raised the following concerns -
1. That probation officers need to understand, and be constantly alert to, the risk of suicide/self-
harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other
evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by
the particular sense of unfairness that they feel about being on an IPP at all, now the sentence
has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the
absence of hope of ever getting off it.
2. Linked to that second point, it is crucial that probation officers are also fully versed in the
processes for suspending parole licence supervision and then cancelling it altogether. One of the
real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should
have been referred for licence cancellation. It did not happen, and it is not clear why, but it may
have been because no-one was actively looking at him given that his supervision had been
suspended. In any event, the referral system did not work and Mr Williams was never referred, at
any stage, for cancellation.
It seems to me that these two concerns at least give rise to a training need.
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
increasing their knowledge and skills around trauma
learning products aimed at
aware/person centred practice, as well as opportunities
to practice motivational
for Effective Engagement Development and
interviewing approaches. The Skills
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.
Guidance for Probation staff on Consideration of the Suitability for Termination of IPP
Licences was issued in September 2023 alongside a 7 Minute Briefing on Termination of
IPP Licence and this is available to staff on EQUiP (as referred to above).
Alongside the learning and development/training being provided to Probation staff
regarding suicide prevention and termination of IPP Licences, 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 these matters.
Yours sincerely,
Director General of Operations
See every Prevention of Future Deaths report matching Alcohol, drug and medication related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.