Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0523, written 1 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Oct 2024 |
|---|---|
| Reference | 2024-0523 |
| Deceased | Brandon Johnson |
| Coroner | Paul Rogers |
| Coroner area | London Inner (West) |
| Category | State Custody related deaths |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Governor, HMP Wandsworth, Heathfield Road, Wandsworth, London 1 CORONER I am Paul Rogers, HM Assistant Coroner, for the Coroner Area of Inner West London 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 Between 24th and 27th June 2024 evidence was heard touching the death of Brandon Valrick JOHNSON who died on 12th September 2019 aged 40 years. Medical Cause of Death I (a) Cardio-Respiratory Failure 1(b) Ischaemic Heart Disease 1(c) Coronary artery atheroma and left ventricular hypertrophy 1(d) Chronic cocaine misuse 2 Schizophrenia, chronic substance misuse How, when, where Brandon Valrick JOHNSON came by his death: On 12th September 2019, Brandon Valrick Johnson suffered cardio- respiratory failure at cell 29, HMP Wandsworth, Heathfield Road, Wandsworth, London. Conclusion of the Jury as to the death: He died from cardio-respiratory failure as a result of poor heart health. Chronic cocaine misuse more than minimally contributed to his poor heart health. 1 (b) Circumstances of the death: Extensive evidence was heard by the court in the form of written and oral evidence, including expert evidence. Of particular significance for the purpose of this report are the following matters: I heard evidence that Brandon was not discovered as deceased until the late afternoon of 12th September 2019 despite a number of attendances at his cell by prison officers and other staff. Rigor mortis and pooling of the blood had been identified. I was told various checks had been undertaken since 0430. I heard evidence that whilst staff knew they needed to obtain positive responses from prisoners and should asess whether the peson is alive and breathing, they had little time in which to do this when combined with other duties. 5 Matters of Concern: I am concerned about the robustness of the procedures and processes for checking that prisoners are alive within their cells. My concern arises because I heard evidence that Brandon was not discovered as deceased until the late afternoon of 12th September 2019 despite a number of attendances at his cell by prison officers and other staff. Rigor mortis and pooling of the blood had been identified. I was told various checks had been undertaken since 0430. I was not confident, having heard and assessed the evidence as a whole that staff had sufficient time to properly check on inmates and obtain positive responses or note obvious signs of life. The checks that were made were for a matter of seconds, and I was not satisfied that the signs of life said to have been noted were sufficiently obvious or reliable to have given appropriate reassurance, or that signs of life were actually being looked for rather than as being incidental to other observations. I am concerned whether all appropriate measures are being taken to perform robust checks at appropriate times that elicit positive responses to indicate that a prisoner remains alive. In addition, I am concerned about how the prison satisfies itself that staff know how and when to perform these checks, what that consists of, and in relation to signs of life/positive response what those are meant to be and where that is set out in the training of staff. Further if checks are performed which elicit a positive life response how are those recorded, who checks this is being done, in what form and how often. 6 ACTION SHOULD BE TAKEN 2 In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. It is for each addressee to respond to matters relevant to them. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. 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: The Family of Brandon Johnson Ministry of Justice I am also under a duty to send the Chief Coroner a copy of your response. 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 1st October 2024 Paul Rogers HM Assistant Coroner Inner West London Inner West London Coroner’s Court 33 Tachbrook Street London SW1P 2ED 3
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 Operations
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London
SW1H 9AJ
Paul Rogers
Assistant Coroner for Inner West London
Inner West London Coroner’s Court
33 Tachbrook Street
London
SW1P 2ED
13 November 2024
Dear Mr Rogers,
Thank you for your Regulation 28 report of 1 October 2024, addressed to the Governor of
HMP Wandsworth, following the inquest into the death of Brandon Johnson on 12
September 2019. I am responding on behalf of His Majesty’s Prison and Probation Service
(HMPPS) as the Director General of Operations.
I know that you will share a copy of this response with Mr Johnson’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 concern about the robustness of the procedures and processes for
checking on the welfare of prisoners within their cells and how the prison ensures that these
checks have been undertaken.
In respect of staff checks on prisoners, it may be helpful for me to first clarify the types of
checks that staff are required to conduct on prisoners.
Roll checks are undertaken as a fundamental security check to ensure that all prisoners are
present in each area of the prison at particular times of the day. While the primary purpose
of these checks is to ensure all prisoners are accounted for, staff are required to take any
necessary action if there are any immediate concerns for a prisoner’s welfare.
Welfare checks are undertaken by staff during or shortly after unlock so they can assure
themselves of the wellbeing of prisoners. This can include verbal or physical
acknowledgements, movement in a cell or in bed, or any other indication that a person is
alive and there are no obvious issues of concern. Further, as part of the Assessment, Care
in Custody and Teamwork (ACCT) process, observations are carried out on those who are
considered to be at risk of self-harm or suicide to ensure these individuals are safe.
Observations are carried out at irregular intervals and in the least obtrusive manner,
particularly at night given the importance of sleep for wellbeing.
All prisons are required to have a local policy which sets out what staff are required to do
during checks in order to ensure the above requirements are met. Local instructions and
policies will supersede initial training as they set out the expectations of that establishment.
I fully recognise the importance of checks being carried out as they should be. HMPPS
would expect staff to take swift action if they have any concerns about an individual’s
welfare no matter what type of check is being conducted.
All staff receive training on the completion of roll checks before they commence their
employment, and continued support is provided to staff by their managers to ensure they
continue to employ good practice. Staff who are identified as needing additional support
with roll check completion will be allocated additional training and development.
HMP Wandsworth’s Local Security Strategy (LSS) provides clear guidance to staff about
the manner and processes of roll check completion. The prison is presently reviewing the
LSS and will consult the roll check policy as part of this review to ensure that there is
continued focus on the importance of staff completing roll checks correctly.
This prison issued a notice to all staff in March 2021 to remind them of the importance of
having clear sight of a prisoner and obtaining signs of life during a roll check. Further
communication and reminders have been published since. In 2024 the prison introduced a
quality assurance process for roll checks where managers were present during their
completion to ensure they were being done effectively. In addition, further support for staff
with understanding the importance of roll checks and assisting staff in their effective
completion was provided by the Standards Coaching Team, who were deployed to HMP
Wandsworth over the summer of 2024.
The completion of roll checks is discussed with staff in daily briefings at HMP Wandsworth.
Staff are reminded to challenge prisoners who obscure their observation panels and
prevent roll checks being completed effectively. They are also briefed on the process for
calling for staff support if they are struggling to obtain a sufficient response during a roll
check on a prisoner.
I hope the measures outlined above provide you with reassurance that learning and
appropriate action has been taken from the circumstances of Mr Johnson’s death.
Yours sincerely
Director General Operations
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