Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0270, written 16 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 May 2024 |
|---|---|
| Reference | 2024-0270 |
| Deceased | Luke Pearce |
| Coroner | Kelly Dixon |
| Coroner area | Staffordshire and Stoke on Trent |
| Category | Suicide (from 2015) |
| 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 Ministry of Justice 2 His Majesty’s Prison and Probation Service (HMPPS) 3 The Governor of HMP/YOI Swinfen Hall 1 CORONER I am Kelly Dixon, Assistant Coroner for the coroner area of Staffordshire and Stoke-on-Trent. 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 12 April 2023 I commenced an investigation into the death of Luke Mikael PEARCE aged 21. The investigation concluded at the end of the inquest on 16 May 2024. The conclusion of the inquest was that: suicide. 4 CIRCUMSTANCES OF THE DEATH Mr Luke Pearce was found hanging in his cell on 6 April 2023, at HMP/YOI Swinfen Hall. He was 21 years old. Mr Pearce had given no indication to staff that he was at risk of suicide or self harm in the months leading up to his death. Shortly after 5.30am on 6 April 2023, during a routine check, The officer called to Mr Pearce but got no response. He looked through the crack of the door and saw Mr Pearce with a ligature around his neck. The officer radioed for urgent assistance but did not use the appropriate coded wording of “Code Blue”. An Operation Support Grade attended and briefly entered Mr Pearce’s cell before coming out again. When another officer attended, the first officer and OSG told her that she should not enter the cell as it was a crime scene. She contacted a custodial manager for permission to go in and then cut the ligature and lowered Mr Pearce to the floor. The officer and OSG waited outside and did not assist. At 5.40am, more staff arrived and the control room staff called an ambulance. Staff started CPR at 05.42am. Ambulance paramedics arrived at 5.59am and took over CPR. At 6.30am, they pronounced that Mr Pearce had died. There was a delay in staff entering the cell, removing the ligature and starting CPR. This did not contribute towards Mr Pearce’s death. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: That relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency, and the appropriate use of Code Blue and Code Red communications in a medical emergency, is not being delivered in a timely manner to appropriate staff. 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 July 11, 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 Mother of the Deceased. I have also sent it to Prisons and Probation Ombudsman 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: 16 May 2024 Kelly Dixon Assistant Coroner for Staffordshire and Stoke-on-Trent 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 Email: Ms Kelly Dixon HM Assistant Coroner for Staffordshire and Stoke-on-Trent Stoke-on-Trent and North Staffordshire Coroners Service Stoke Town Hall Kingsway Stoke-on-Trent ST4 1HH 17 July 2024 Dear Ms Dixon, Thank you for your Regulation 28 report of 16 May 2024, addressed to the Ministry of Justice, His Majesty’s Prison and Probation Service (HMPPS), and the Governor of HMP/YOI Swinfen Hall. I am responding on behalf of HMPPS as Director General of Operations. I know that you will share a copy of this response with Mr Pearce’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. You have expressed concerns concerning the timeliness of training and guidance provided to staff with regards to medical emergency procedures, including the entering of cells and the appropriate use of medical emergency codes. During the inquest, evidence was heard concerning the new national video that was launched in January 2024. The video includes a demonstration on how staff should respond to an emergency situation, which includes instructions on when to enter a cell in an emergency and the appropriate use of Code Blue and Code Red communications. This video has been made available to all HMPPS staff, including Officer Support Grades (OSGs) and staff completing night duties who may need to respond to a medical emergency. Since January 2024, the video has been delivered to all new officers via foundation training and has been shared locally with Governing Governors. I have received assurance from the Governor of HMP/YOI Swinfen Hall that the emergency response training video is being shown to all existing members of staff as part of their Safety Critical training, with the view for this to be achieved by March 2025. Going forward, HMP/YOI Swinfen Hall will also ensure that the video is shown annually to all staff. Additionally, Custodial Managers have been instructed to brief all staff at the beginning of night duty about the use of Code Blue and Code Red and entering cells in a medical emergency, which will be subject to quality assurance checks by both the Safety and Security departments. As part of HMP/YOI Swinfen Hall’s local training programme, staff will be trained to understand when it is appropriate and necessary to enter a cell during patrol state and guidance on emergency response procedures will be issued to staff every 6 months. 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 of Operations
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