Prevention of Future Deaths reports · 2024

Darren Docherty

Regulation 28 report to prevent future deaths, reference 2024-0197, written 14 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report14 Apr 2024
Reference2024-0197
DeceasedDarren Docherty
CoronerEmma Serrano
Coroner areaStaffordshire and Stoke on Trent
CategoryState Custody related deaths · Suicide (from 2015)
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 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  HMP Stoke Heath 

2.  Local Authority for Stoke on Trent 

1 

CORONER 

I am Emma Serrano, Assistant Coroner, for the Coroner area of Staffordshire 

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 the 1st  September 2023, I commenced an investigation into the death of Mr Darren 
Clifford Docherty.  The investigation concluded at the end of the inquest on 8 April 2024. 
The conclusion of the inquest was a short form conclusion of suicide. 

The cause of death was: 

1a  Ligature Suspension 

4 

CIRCUMSTANCES OF THE DEATH 

i)  Mr  Docherty was released from HMP Stoke Heath  on  the  4  August 2023. 
He  had  a  history  of  mental  health  difficulties,  self-harm  and  drugabuse. 

ii)  On  his  release  from  prison  he  had  no  accommodation. This  meant  that  he 
was unable to be referred to the Community Mental Health Team or access 
a GP. 

iii)  On  the  10  August  2023  he  was  found  hanging  from  a  tree  in  a  woodland 

area between Whittle Road and Mollison Road in Stoke-on-Trent. 

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.  – 

1.  That when people are released from prison they do so, on many occasions, with 
no accommodation.  Those that need GP access and community mental health 
services are unable to access them in these circumstances. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have the 
power to take such action. 

1 

[IL1: PROTECT] 

 
  
 
 
 
 
 
 
 7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 1 June 2024. 

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: 

1.  Family of the deceased; 

2.  Stoke-on-Trent Probation Service 

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 

14 April 2023 

Miss Emma Serrano 
Area Coroner 
Staffordshire Area 

2 

[IL1: PROTECT]

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 Stoke on Trent Council (PDF)
Response to a Report made Pursuant to Regulation 28 of the Coroners

(Investigations) Regulations 2013 in respect of Darren Clifford Docherty.

I,

, Director of Housing, Development and Growth provide this response

on behalf of Stoke -on-Trent City Council following a report made by His Majesty’s

Assistant Coroner Emma Serrano under Regulation 28 of

the Coroners

(Investigations) Regulations 2013 (“the Report”) dated 14th April 2024

Mr Darren Clifford Docherty was released from HMP Stoke Heath on the 4th August

2023.

He sadly died on 10th August 2023.

We would wish at the outset to acknowledge the tragedy of Mr Docherty’s death and

express our deep sympathy to his family and friends.

In her Report, the Coroner raised the following matter of concern:

1. That when people are released from prison they do so, on many

occasions, with no accommodation. Those that need GP access and

community mental health services are unable to access them in

these circumstances.”

The Council has considered the concern raised by the Coroner and has identified

there are two parts to address:

a. being released from prison without accommodation; and

b. how not having accommodation creates barriers to accessing community

health and mental health services.

Being Discharged from Prison Without Accommodation

The Homelessness Reduction Act 2017 (“the Act”) places a number of duties on

local housing authorities including:

  a duty to provide advice and information about homelessness and the

prevention of homelessness and the rights of homeless people or those at risk

of homelessness;

 a duty to carry out an assessment in all cases where an eligible applicant is

homeless or threatened with homelessness;

 a duty to take reasonable steps to help prevent any eligible person

(regardless of priority need status, intentionality and whether they have a local

connection) who is threatened with homelessness from becoming homeless;

 a duty to help the applicant to secure accommodation if they are already

homeless, or become homeless despite activity during the prevention stage;

and

 a duty to provide interim accommodation if the housing authority has reason

to believe a homeless applicant may be eligible for assistance and have a

priority.

The Act also introduced a duty on certain public authorities, including prisons, to

refer service users who they think may be homeless or

threatened with

homelessness to a housing authority. The service user must give consent, and can

choose which authority to be referred to.

The duty to refer helps to ensure that services work together

to prevent

homelessness by ensuring that applicants’ housing needs are considered when they

come into contact with public authorities.

Upon receiving a referral, the local authority should contact the service user using

the contact details on the referral and carry out an assessment to establish what

duties are owed. The local authority will, as part of its enquiries, establish if the duty

to provide interim accommodation is met. This would apply to those households that

are classed as having a priority need.

Despite the `Duty to Refer,` there is no absolute duty on a local housing authority to

provide accommodation for all households or individuals who present as homeless.

It should be acknowledged and noted that most local authorities, including Stoke-on-

Trent, will provide accommodation for certain non-priority households at

their

 discretion. Local authorities cannot offer this for every request made as the cost

would be prohibitive.

Access to GP and Community Mental Health Services

Whilst the local authority does not commission GP or community mental health

services and is therefore not in a position to directly address these concerns, it is

aware that homelessness should not be a barrier to registration with a GP.

Further information from the NHS can be found here: how-to-register-with-a-gp-

homeless.pdf (assets.nhs.uk)

Stoke-on-Trent City Council Response

With regard to Mr Docherty and others who are about to be released from prison, the

Council acknowledges that it has an important role to play in conjunction with other

key strategic partners.

The Council has the following services and processes in place to respond to these

situations:

 A portal

for agencies to submit

‘Duty to Refer’ referrals to the Housing

Solutions service;

 A Duty Team which is operational every weekday during normal office hours

(9am – 5pm Monday-Thursday, 9am-4.30pm Friday) and is contactable by

telephone or via Stoke-on-Trent One Stop Shop for all households that are at

risk of being homeless that night;

 An Emergency Duty Team (EDT) which operates out of hours to take

`Homeless Tonight` enquiries, undertake homelessness and priority needs

assessments and make offers of accommodation as appropriate;

 A Rough Sleepers Outreach Service to contact any individual sleeping rough

in the City identified either through self-referral, sign posting from EDT or

Streetlink referral and refer into support services;

  An immediate off the street offer for any household verified by the Rough

Sleeper’s Team as rough sleeping and not having previously slept rough in

the City and received an offer of accommodation;

 Hanley Connects Homelessness Hub at Hillcrest in Hanley, open 5 days a

week where homeless households can access support services including

accommodation providers, drug and alcohol treatment, health and mental

health services as well as a hot meal, clean clothes and washing facilities;

 A mobile Homeless Healthcare Service provided by specialist nurse

practitioners who will provide an outreach service to individuals sleeping

rough in the City including treatment of wounds etc and support to register

with a GP;

 A specialist Rough Sleeping Mental Health practitioner who provides an

outreach service including initial assessment and referral

into wider Mental

Health services;

 A specialist Rough Sleeping Drug and Alcohol Outreach team who provide an

outreach service including initial assessment and referral into wider specialist

treatment and recovery services;

 A specialist Resettlement Officer working directly with prisons to develop a

robust accommodation pathway and liaison on individual cases;

 A wide range of supported accommodation for rough sleepers and those at

risk of sleeping rough including accommodation specifically for those who

have had contact with the Criminal Justice system;

 Excellent contacts with the Probation Service to make links with their CAS3

service to provide accommodation for certain individuals leaving custody with

no fixed abode.

The vast majority of these services are funded from short term Government grants

such as the Rough Sleeping Initiative and Changing Lives.

In respect of Mr Docherty, the Council received a Duty to Refer referral on the 18th

July 2023 which advised a release date of 4th August 2023. Although the Council

was unable to speak to Mr Docherty prior to his release, an email was sent to the

Probation Service on the day of release advising of how Mr Docherty could present

 to the Service.

Mr Docherty presented to the City Council Duty Team on the day of his release (4th

August) and an officer completed a full assessment that determined he was not in

priority need in accordance with the provisions of the Housing Act 1996 as amended

by the Homelessness Reduction Act 2017 and the associated Homelessness Code

of Guidance for Local Authorities. The Local Authority therefore did not owe Mr

Docherty a duty to provide interim accommodation and general advice about

securing accommodation elsewhere was provided. The officer continued making

enquiries over the next few days requesting further information and advised the

Probation Service on 9th August that the non-priority decision had been confirmed

but could be reassessed upon further information being submitted.

The Coroner’s Report concludes by stating;

In my opinion action should be taken to prevent future deaths and I

believe you have the power to take such action.”

The Council has considered this matter carefully following its investigation with

regard to its involvement with Mr Docherty.

The Council will therefore undertake to take the following steps to strengthen the

procedures already in place:

1. We have already completed a review of the Duty to Refer process to ensure

all referrals receive a response within 3 days of receipt so that prisoners due

for release and their representatives in the prison service are aware they need

to either approach the Housing Solutions Service within office hours or the

Emergency Duty Team outside of office hours if they are released with no

accommodation secured on the day of their release;

2. We will continue to work with prisons to ensure robust procedures are in place

for those being released at risk of homelessness through already established

mechanisms such as the pre-release panel, a joint meeting between prison

based accommodation staff and the Council’s dedicated Housing Needs

 Resettlement Officer within our service;

3. We will continue to work with partners across the prison service to ensure a

clear referral pathway is in place above and beyond the Duty to Refer

mechanism so that everyone has a better understanding of

the housing

options available before a prisoner

is released, however,

it must be

recognised that this is unlikely to result in a firm offer of accommodation for

everyone especially those that have no priority need;

4. We will continue to work with colleagues in health and social care to support

individuals released from prison with no accommodation to access GP and

community mental health services by ensuring they are aware of and linked

into the existing Homeless Healthcare Service and Rough Sleeping Mental

Health nurse and the wider support available through Hanley Connects, the

City Council’s Homelessness Hub and the Rough Sleeper Outreach Service.

We as a Local Authority take our responsibilities to those leaving custody extremely

seriously but

regrettably do not have sufficient accommodation or

resources

available to make an offer of immediate accommodation at the point of presentation

to everyone regardless of priority need. It is therefore suggested that the Coroner

may wish to separately consider making a Report to Central Government in terms of

the legal duties that apply to offers of interim accommodation, especially for those

leaving custody and the allocation of funding to Local Authorities to provide this.

Although it is not part of the remit of this report, the Council would also like to

express its concern that the End of Custody Supervised License (ECSL) scheme to

ease overcrowding in jails across England and Wales, which has recently been

extended to allow certain prisoners to be released up to 70 days before the end of

their sentence, will place additional pressures on already overstretched Local

Authorities to find accommodation for those released with no fixed abode or where

insecure accommodation upon release breaks down.

I understand that this response may be shared with all interested persons and would

therefore wish to take this opportunity to express my sincere condolences to Mr

Docherty’s family on behalf of Stoke on Trent City Council.

 ………………………. Signed
10/06/24………………………..Dated

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