Marlin Burrows

Trust Management Offices 
First Floor, The Curve 
Bury New Road 
Prestwich 
Manchester 
M25 3BL 

PRIVATE AND CONFIDENTIAL   
Mr Nicholas Rheinberg 
Lancashire and Blackburn with Darwen Coroners Office  
2 Faraday Dr  
Fulwood  
Preston  
PR2 9NB 

18th June 2024 

Dear Mr Rheinberg 

Re: Marlin John Burrows (DoB 13/02/1977 DoD 16/08/2022) 

Thank you for highlighting your concerns following the inquest of Mr Burrows, which concluded 
on the 29th of April 2024. On behalf of Greater Manchester Mental Health NHS Trust, I would 
like to offer Mr Burrows’ family our sincere condolences for their loss. 

During the inquest you heard evidence that gave rise to the following matters of concern:   

(1)  The  existing  welfare  sheet  lacks  clarity  as  to  its  exact  purpose  in  terms  of 

monitoring a prisoner whose health is of concern.  

(2)  The sheet contains little guidance in relation to its completion.  
(3)  Entries  on  the  sheet  made  by  prison  staff  appear  not  to  be  made  known  to 

attending medical staff.  

(4)  The nature and operation of the sheet appears not to have been the subject of 

joint consideration on behalf of both Prison and Healthcare. 

Following the conclusion of the Inquest, 
met with the Governors of HMP Garth, 
concerns.  

, Head of Healthcare for HMP Garth has 
, to address these 

Our prison partners have informed us that nationally the picture has changed. His Majesties 
Prison and Probation Service (HMPPS) are developing national guidance for the management 
of people under the influence and that this process is currently going through consultation with 

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,  
Bury New Road, Prestwich, Manchester M25 3BL. 

Page 1 of 2 

 
                                                                                                                
 
                                                                                                                                                                        
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 their  recognised  trade  unions.  This  national  policy  will  address  the  concerns  you  raised  in 
points 1, 2 and 4.  

In respect of point 3 Entries on the sheet made by prison staff appear not to be made 
known to attending medical staff  

All Healthcare staff attending prisoners have been informed that they must request the welfare 
checklist document on arrival at the wing, ensuring they have read and understood the entries 
to inform clinical decision making. This will be evidenced by them signing the sheet to say they 
have  reviewed  the  information  and  their  entry  in  the  clinical  record  will  state  they  have 
reviewed  the  welfare  checklist  and  communicated  with  prison  staff  as  part  of  their  clinical 
assessment. In addition to this, assurance checks will be completed monthly by the Primary 
Care  Manager  who  will  review  the  welfare  check  sheets  ensuring  the  attending  staff  have 
reviewed and signed the sheets as part of their assessment.  This will be cross referenced 
with the clinical record to ensure that this information was considered when undertaking the 
assessment. 

A  Standard  Operating  Procedure  (SOP)  will  be  co-produced  with  prison  staff  following  the 
publication  of  national  guidance  from  HMPPS  for  prisoners  who  present  as  under  the 
influence.  This  SOP  will  be  shared  widely  with  colleagues  across the  prison. We  would  be 
happy to provide a copy of this document to your Coronial Office should you wish.  

In addition, the Head of Nursing and Quality for the Health & Justice Division at GMMH will 
work with the Healthcare staff at HMP Garth to develop some training and awareness sessions 
for prison staff around the use of the welfare checklist and the associated guidance once the 
national policy is implemented. 

Can I thank you again for bringing these matters of concern to the Trust’s attention. I hope our 
response has gone some way to address your concerns. If you have any further questions in 
relation to the Trust’s response, please do let me know. 

Yours Sincerely 

Medical Director 
GMMH 

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,  
Bury New Road, Prestwich, Manchester M25 3BL. 

Page 2 of 2

OFFICIAL

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

Mr Nicholas Rheinberg 
HM Assistant Coroner, Liverpool & Wirral  
Gerard Majella Court House 
Boundary Street 
Liverpool 
L5 2QD 

September 2024 

Dear Mr Rheinberg, 

Thank you for your Regulation 28 report of 30 April addressed to the Governor and Head of 
Healthcare at HMP Garth following the inquest into the death of Marlin Burows on 16 
August 2022 at HMP Garth. I am responding as Director General of Operations for His 
Majesty’s Prison and Probation Service (HMPPS). I am grateful to you for granting an 
extension for our response.  

I am aware that Greater Manchester Mental Health (GMMH) NHS Foundation Trust have 
responded separately and therefore my response will focus on matters within the remit of 
HMPPS. 

I know that you will share a copy of this response with Mr Burrows’ 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 concerns about the welfare check 
processes at HMP Garth, including the welfare check sheet used by staff to monitor 
prisoners who are suspected of being under the influence of illicit substances. I am grateful 
to you for bringing your concerns to my attention. 

I am pleased to inform you that HMPPS is currently developing national guidance for all 
staff managing prisoners who are under the influence of illicit substances. The guidance has 
been developed by the national Substance Misuse Group with contributions from internal 
and external stakeholders, including from areas such as health, and safety. Its purpose is to 
provide structured guidance for prisons to support the development of local under the 
influence guidance that will ensure that there is a consistent and safe response to the 
management of prisoners. It is important to note that this guidance does not replace 
healthcare advice and in a medical emergency instructions and advice from healthcare 
colleagues must be followed as a priority.  

The guidance is currently in the consultation stage, and while I am hopeful that this will go 
live by the end of the year this will be dependent on what the consultation identifies and 

OFFICIAL

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL

whether further changes are required. I can confirm that your concerns have been shared 
with the Substance Misuse Group for consideration to ensure that the guidance addresses 
them. 

Once agreed, the guidance document will be rolled out via the regional and local drug 
strategy leads, and they will be responsible for developing local guidance. The Substance 
Misuse Group will deliver additional training and support if necessary, and through their 
rolling programme of support, assurance checks will be conducted to ensure that under the 
influence guidance has been developed and embedded at each prison.  

In the meantime, I have received assurance from the Governor of HMP Garth that following 
the inquest meetings have been held between prison and healthcare colleagues to ensure a 
joined up approach going forward. Once national guidance is available, a standard 
operating procedure will be produced so that all prison and healthcare staff understand 
what they are expected to do when carrying out welfare checks on prisoners being 
monitored under the influence. GMMH have also committed to developing local training and 
awareness sessions around the use of the welfare check sheet once national guidance has 
been published. 

I am also informed that healthcare staff now request the welfare sheet upon arrival onto 
wings to ensure that they have had the opportunity to review and consider entries that may 
inform any clinical decision making. 

Thank you again for bringing your concerns to my attention. I hope that this response 
provides assurance that action is being taken to address your concerns.  

Yours sincerely 

    Director General of Operations, HMPPS 

OFFICIAL