Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0393, written 22 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jul 2024 |
|---|---|
| Reference | 2024-0393 |
| Deceased | Russell Irvine |
| Coroner | Simon Connolly |
| Coroner area | Durham & Darlington |
| Category | State Custody related deaths · 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 1 CORONER I am Simon CONNOLLY, Assistant Coroner for the coroner area of County Durham and Darlington 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 10/11/2022 12:04an investigation was commenced into the death of Russell Ian IRVINE 22/07/1971 00:00:00. The investigation concluded at the end of the inquest on 21/06/2024 14:36. The conclusion of the inquest was that Hanging - 7 November 2022 - HMP Durham, cell E3-03, Old Elvet, Durham, DH1 3HU. See Attached: We believe on the balance of probabilities that Mr Irvine had the intentions and took his own life on the evening of 7 November 2022 by hanging in his prison cell, Mr Irvine also left a note in which he stated he was of sound mind. Based on the evidence provided, the facts state that a number of policies and processes were not actioned or put I place correctly. It is evident that Mr Irvine had previously documented risk factors for suicide and self- harm, however these factors were not identified by prison staff during the reception screening process. It is evident that not all of the actions taken by healthcare were in compliance with the relevant policies. It cannot be established on the evidence that these failings caused or contributed to Mr Irvine's death.. 4 CIRCUMSTANCES OF THE DEATH Hanging - 7 November 2022 - HMP Durham, cell E3-03, Old Elvet, Durham, DH1 3HU. See Attached: We believe on the balance of probabilities that Mr Irvine had the intentions and took his own life on the evening of 7 November 2022 by hanging in his prison cell, Regulation 28 – After Inquest Document Template Updated 30/07/2021 Mr Irvine also left a note in which he stated he was of sound mind. Based on the evidence provided, the facts state that a number of policies and processes were not actioned or put I place correctly. It is evident that Mr Irvine had previously documented risk factors for suicide and self- harm, however these factors were not identified by prison staff during the reception screening process. It is evident that not all of the actions taken by healthcare were in compliance with the relevant policies. It cannot be established on the evidence that these failings caused or contributed to Mr Irvine'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. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Russell Ian Irvine died three days after his entry into HMP Durham on 4 November 2022 following his licence recall into custody, about which he protested and told reception healthcare staff that he had refused food and fluids for the previous two days. The evidence demonstrated that this information was not escalated in accordance with established policy which meant that Mr Irvine's food and fluid intake was not adequately or at all monitored by prison wing staff. As to food and fluid monitoring generally and notwithstanding the availability of internal policies mandating necessary action in cases of known food and fluid refusal, evidence from prison officers at inquest was to the effect that no formal policy existed to monitor and identify whether a prisoner had collected their meal and so had necessary sustenance at least available to them. The absence of such policy was identified by the Prison and Probation Ombudsman during its investigation as to the circumstances of Mr Irvine's death and this formed a recommendation within the Ombudsman's report. HMP Durham's response to this recommendation was the introduction of process and form to record instances when a prisoner failed to collect their meal as a means of monitoring their intake. Evidence from a prisoner Governor was to the effect that she was not aware that such a process or form was in use at any other establishment within the nationwide secure estate, enquiries having been made to substantiate this. The concern is that other such establishments operate without the advantage of the safeguard now employed at HMP Durham with the risk of future deaths occurring elsewhere evident. 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 September 13, 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the Regulation 28 – After Inquest Document Template Updated 30/07/2021 timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to HMP Durham 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: 22/07/2024 Simon CONNOLLY Assistant Coroner for County Durham and Darlington 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: 20 September 2024 Simon Connolly Assistant Coroner County Durham and Darlington Fourth Floor Civic Centre, North Terrace Crook County Durham DL15 9ES Dear Mr Connolly Thank you for your Regulation 28 report of 22 July, addressed to Chief Executive of HM Prison and Probation Service (HMPPS). I am responding on behalf of HMPPS as Director General of Operations. , the Director General I know that you will share a copy of this response with Mr Irvine’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 raised a concern that there is no formal policy to identify whether a prisoner has collected their meal and suggested that a process or form should be put in place as a means of monitoring food intake. As you know our policy (currently Prison Service Instruction 64/2011, shortly to be replaced with a new policy framework on prison safety in which this section remains unchanged) already notes the importance of identifying food and/or fluid refusals early, and explains that staff should monitor attendance at mealtimes and note when prisoners return meals uneaten. It mandates that information about food and/or fluid refusals be recorded, shared and remain accessible to all relevant staff and requires prison staff to work closely with healthcare staff to manage those refusing food and/or fluids, pointing to the detailed clinical guidance document issued by the Department of Health and Social Care. Food and/or fluid refusals are also reportable incidents in our incident management manual policy framework, and our national incident management unit frequently receives reports of such incidents from prisons across the estate. I understand your concern to ensure that this policy is translated into practical action, but in view of the range of catering and food service arrangements across the prison estate I do not believe that the introduction of a single process or form would be operationally viable. I believe that a better way forward is to ask Governors to assure themselves that their local reporting processes are operating effectively. I will ensure all Governors are written to so that this case is brought to their attention and to ask them to remind staff of their role in early identification of food and/or fluid refusals and to satisfy themselves that there are systems in place for recording information and sharing it with healthcare providers. As always, we remain committed to prisoner safety as our key priority. Thank you again for bringing this matter of concern to our attention. I trust that this response provides assurance that action is being taken to address it. Yours sincerely, Director General of Operations
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