Prevention of Future Deaths reports · 2024

Scott Rider

Regulation 28 report to prevent future deaths, reference 2024-0210, written 12 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report12 Apr 2024
Reference2024-0210
DeceasedScott Rider
CoronerTom Osborne
Coroner areaMilton Keynes
CategorySuicide (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 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT DEATHS  

THIS REPORT IS BEING SENT TO: 

1 

, Minister of State for Prisons, Parole and Probation 

1  CORONER 

I am Tom OSBORNE, Senior Coroner for the coroner area of Milton Keynes 

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 17 June 2022 I commenced an investigation into the death of Scott William James Rider 
aged 45. The investigation concluded at the end of the inquest on 20 March 2024. The 
conclusion at the end of the inquest was that Scott Rider died as the result of: 

Suicide 

4  CIRCUMSTANCES OF THE DEATH as determined by the jury. 

Scott Rider was a prisoner at HMP Woodhill, serving a sentence of Imprisonment 
for Public Protection. This was a sentence of indeterminate length. The minimum 
tariff was 23 months. Scott had been in prison for 17 and a half years at his time 
of death. Scott was transferred to HMP Woodhill on 30th June 2021 and after 
leaving the induction unit he was moved to House Unit 4A. He had been self-
isolating for over 200 days. 
He was supported by members of staff to the best of their capacity under 
the circumstances, but did not always engage. 
There was no outward indication prior to Scott's death that he had an increased 
risk of suicide at that time. Scott's aim was to be transferred to another prison in 
the North. 
At the time of Scott's death, there were inadequate staffing levels and 
the continuing length of his sentence was uncertain. 
On the 13th June 2022, Scott was found hanging in his cell with a ligature 
around his neck. 

5  CORONER’S CONCERNS 

During 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) 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
  
 
 One of the findings of the Prisons and Probation Ombudsman was that Mr Rider was one of 
many IPP prisoners struggling to progress in his sentence and had limited hope for release. 
The Governor of the prison in her evidence to me, spoke about indeterminate sentences 
and said "In my personal view they are indefensible". She went on to say "We find that 
some of the most challenging behaviours are from this group of men who feel trapped." 
The governor also commented that if I were to submit a Regulation 28 report to the 
Minister for Prisons; "most Prison Governors would welcome that intervention." On the 9th 
September 2005 Mr Rider received an Imprisonment for Public Protection (IPP) sentence 
with a tariff of 23 months; at the time of his death he had served seventeen and half years 
and had given up all hope of release. On any consideration of the circumstances of Mr 
Rider's death one has to conclude that his treatment was inhumane and indefensible and 
that if action is not taken to review all prisoners sentenced to IPP then there is a risk of 
further deaths occurring. 

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 23, 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 

 – sister of Scott Rider. 

The Governor of HMP Woodhill. 
The Head of Healthcare at HMP Woodhill. 

I have also sent it to: 

The Prison and Probation Ombudsman 
HM Inspector of Prisons 
Executive Director of Inquest 

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: 12/04/2024 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
  
 
 Tom OSBORNE  
Senior Coroner for  
Milton Keynes 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

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)
OFFICIAL 

Director General Operations 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London  
SW1H 9AJ 

Tom Osborne  
Senior Coroner for Milton Keynes 
Civic 
1 Saxon Gate East 
Milton Keynes  
MK9 3EJ 

Dear Mr Osborne 

15 May 2024 

Thank you for your Regulation 28 report of 12 April 2024 addressed to His Majesty’s Prison 
and Probation Service (HMPPS). I am responding as Director General of Operations. 

I know that you will share a copy of this response with Mr Rider’s family, and I would first 
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 some concerns regarding the 
Imprisonment for Public Protection (IPP) sentence. Thank you for bringing your concerns to 
my attention. 

I recognise the challenges raised within your report in relation to those serving IPP 
sentences. HMPPS remains fully committed to supporting the progression of those 
prisoners serving IPP sentences to the point where the independent Parole Board 
determines that they may be safely released. In 2023, 189 IPP prisoners were released for 
the first time and 448 IPP prisoners were re-released following recall. HMPPS is also fully 
committed to supporting those serving IPP sentences in the community, including by 
referring them to the Parole Board at the point they become eligible for consideration to  
have their IPP licence terminated. 

You may be aware that the Justice Select Committee (JSC) published their report into the 
IPP sentence in September 2022, following a year-long inquiry. The Government believes 
the report provided a valuable opportunity to take stock and identify areas for improvement 
which will make a genuine difference to the way that those serving IPP sentences are 
rehabilitated and supported through safe release, or termination of the licence, where 
appropriate.  

The Government accepted the Committee’s recommendation to review the IPP Action Plan 
and shared the outcome of the review, which HMPPS delivered, with the Committee on 26 
April 2023 which can be accessed here: 
https://committees.parliament.uk/publications/39321/documents/192968/default/   

OFFICIAL 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

Over recent years HMPPS has made considerable progress when it comes to supporting 
those serving IPP sentences towards release, although the release decision itself is for the 
independent Parole Board to take, and the Board will release a prisoner only where it is 
safe to do so. Our IPP Action Plan is led at Director level to ensure there is senior level, 
robust accountability for its delivery. 
West, South Central & Public Protection, has taken this lead role. He has established the 
IPP Progression Board, which has met four times across this first year of the Action Plan. 
The Progression Board is used to hold all workstream owners to account for their delivery of 
actions within the Action Plan. 
Challenge Group, ensuring that our work and focus is subject to regular scrutiny and 
accountability from the key campaign groups and independent bodies for the work we are 
delivering.  

 is also chair of the important External Stakeholder 

, Area Executive Director for the South 

A full list of achievements in the delivery of the IPP Action Plan will be published in June 
2024, in our IPP annual report. However, I can report on some of our achievements over 
the last year and am pleased to announce that HMPPS has expanded psychology services 
through the prison gate and into the community, to support some of the most complex 
people we work with. HMPPS has also published the refreshed Offender Personality 
Disorder (OPD) Programme strategy which includes, for the first time, a specific focus on 
the IPP cohort, a large proportion of whom screen into the OPD Pathway. The OPD 
pathway is a jointly funded partnership between HMPPS and NHS England. The refreshed 
strategy can be accessed here: https://www.england.nhs.uk/long-read/the-offender-
personality-disorder-pathway/  

I recognise that it is vital for HMPPS to ensure its work focuses on real change and support 
which can be felt in prisons and in the community for those on licence. In February 2024, I 
commissioned each of the seven Area Executive Directors commands for England and 
Wales, as well as the Executive Directors of the Long-Term High Security Estate, the 
Women’s Estate and Contracted Prisons to develop operational IPP delivery plans and to 
begin delivering those plans in the Summer of 2024. These Delivery Plans will directly 
target front-line delivery in support of helping those serving IPP sentences to work on and 
achieve the objectives within their sentence plans, and move towards a future prospective 
safe and sustainable release and, when in the community, towards a future termination of 
their licence. Specifically, the IPP delivery plans will: 

•  ensure each IPP prisoner has an up-to-date sentence plan; 
•  ensure those serving an IPP sentence are in the correct prisons to access relevant 
support and rehabilitative services contained within their up-to-date sentence plans; 

•  ensure timely and high-quality preparation for parole and release; 
•  assist with community reintegration and the effective management of the IPP cases 

on licence; 

•  ensure staff complete specific IPP sentence-related staff development and training; 

and 

•  ensure those serving an IPP sentence who are at risk of self-harm and suicide are 

actively identified and supported.  

The plans include critical success factors (not part of formal HMPPS performance 
management) which will be used to track progress of the IPP population across each area 
and directorate. Progress will be tracked by each area and centrally through the IPP 
Progression Board. 

OFFICIAL 

 
 
 
 
 
 
 
 OFFICIAL 

Reducing the number of self-inflicted deaths in custody is a key priority for me and HMPPS. 
Staff work hard to identify and support prisoners at risk of suicide and self-harm.  

HMPPS Safety Team has a dedicated team member who focuses on the safety of IPP 
prisoners. In May 2023, the Safety Team produced a learning bulletin sharing early learning 
from the self-inflicted death of IPP prisoners. The bulletin provided guidance for suggested 
actions staff can take, including the importance of considering IPP prisoners heightened 
level of risk. In November 2023, the Safety Team delivered a safety briefing to front-line 
staff to further raise awareness on the risks of IPP prisoners. A further session was also 
held during a dedicated ‘IPP in Focus’ week, during the week of 22 April 2024, which was 
attended by high numbers of staff. The sessions during this week were all recorded for 
wider dissemination across prisons and probation delivery units across England and Wales. 
The Safety Team have also developed a Safety Toolkit, with a range of learning and 
practice materials to help front-line staff support those serving the IPP sentence effectively, 
recognising the heightened level of risk of self-harm and suicide among IPP prisoners. 

Our refreshed IPP Action Plan, which will be published in June along with our IPP annual 
report, now has a workstream dedicated to Safety with the main objective of supporting 
Prisons to deliver improvements to the safety of those serving an IPP sentence by actively 
identifying and supporting IPP prisoners at risk of self-harm and violence in custody, whilst 
supporting their engagement and progression. Our primary focus is on raising awareness of 
the heightened risk of self-harm and suicide of IPP prisoners so all staff understand the risk 
factors and can provide effective support.  

We will continue to monitor, analyse and share any changing or emerging trends in 
published IPP prisoner data with staff and to inform and update our guidance where 
appropriate. This will include using an upcoming data “snapshot” of segregated and isolated 
individuals across the Prison Estate to determine the proportion of IPP prisoners in these 
conditions, sharing our findings and highlighting the risk of long-term segregation on the 
mental health of IPP prisoners. 

Further to our work outlined above, we are also mindful that the provision of health services 
to people in prison is the responsibility of the Department for Health and Social Care 
(DHSC). In that respect, we are also engaging with DHSC to identify any possible 
opportunities for a collaborative approach to identifying and then addressing the health 
needs of those serving IPP sentences. 

Reforming the IPP sentence is a priority for the Lord Chancellor and the Government, and 
this is why they are taking decisive action to legislate and bring about a more definitive end 
to the sentence for many who are serving it. The JSC report into the IPP sentence 
(September 2022) also recommended reducing the qualifying period for licence termination 
from 10 years to five years. The Government was particularly persuaded by this and is 
taking forward changes in the Victims and Prisoners Bill to reform legislation relating to the 
termination of the licence for IPP offenders by making amendments to section 31A of the 
Crime (Sentences) Act 1997, which provides for the termination of IPP licences. 

The new measure, subject to the views of Parliament, will: 

a.  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; 

OFFICIAL 

 
 
 
 
 
 
 
 
 
 OFFICIAL 

b.  include a clear statutory presumption that the IPP licence will be terminated by 

c. 

the Parole Board at the end of the three-year qualifying period;  
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, so long as the offender is not recalled in that period.  

The Government is, therefore, going further than the JSC recommended by reducing the 
qualifying period to three years. These amendments will restore greater proportionality to 
IPP sentences and provide a clear pathway to a definitive end to the licence and, therefore, 
the sentence. The Bill has not received Royal Assent and is currently being scrutinised by 
the House of Lords. 

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 Operations 

OFFICIAL

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