Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0667, written 25 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Nov 2024 |
|---|---|
| Reference | 2024-0667 |
| Deceased | Jonathon Lawlor |
| Coroner | Catherine Wood |
| Coroner area | Mid Kent and Medway |
| Category | State Custody related deaths · Alcohol, drug and medication related deaths |
| Organisation named | Oxleas NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Mid Kent and Medway Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Telephone: Email: Date: 25 November 2024 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HM Prison and Probation Service 1. CORONER I am Catherine Wood, Area Coroner for Mid Kent and Medway 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 27 October 2023 I commenced an investigation into the death of Jonathon Paul LAWLOR. The investigation concluded at the end of the inquest . The conclusion of the inquest was The deceased died as a result of an accident. 1a Acute Multi-Organ Failure With Pulmonary Congestion and Oedema 1b Cocaine Toxicity 1c 1d II 4. CIRCUMSTANCES OF THE DEATH The deceased was held on remand at HMP ELMLEY where he had been since 24/06/2023. He was resident in a single cell in house block 4 having spent some time in the inpatient department. There was evidence heard that he had previously used drugs but not in the prison environment itself and he was never observed by staff to be under the influence of substances. On the morning of 19th October 2023, he was seen a number of times but did not leave his cell as he complained of a headache, he did not wish to attend healthcare. At 11:29 hours a prison officer attended his cell to begin lunch procedures when he discovered the deceased laying face down on the floor of his cell unresponsive. The deceased had a small superficial injury to his head on the right side, and his head and shoulders were beneath his metal framed bed, with his body laying diagonal across the room coming out from the bed. The officer immediately declared an emergency and commenced CPR. Other officers attended to assist, and at 11:40 prison Doctor arrived and commenced treatment, this included use of a Defibrillator which found no shockable rhythm. At 11:47 hours the Doctor declared life extinct, and a post mortem revealed he had died as a consequence of Cocaine toxicity. 5. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will 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] (1) Mr. Lawlor only had two keywork sessions during the 4 months he was on remand at HMP Elmley. The reasons given were that staff shortages meant that key working sessions were not able to be offered. Offender Management in Custody(OMiC) guidance suggests that good practice entails an officer having a caseload of five or six prisoners who they will meet once a week for a key working meeting. The Prison and Probation Ombudsman who also investigated the death were aware that due to staff shortages the priority at the time of Mr. Lawlor's death were to have monthly sessions and that the prison was to increase provision as their staffing picture improved. On that basis they made no recommendations. Whilst the number of keywork sessions Mr. Lawlor had did not play a part in his death it may be the case that key-working sessions for prisoners can assist with reducing risks for others in custody. Evidence heard at the inquest revealed that the target had been unachievable due to staffing pressures and as a large number of prisoners (approximately 70%) are on remand and stay between zero and six months the turnover is high and the prison is busy. There was also some scepticism as to whether it was the right model. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you HM Prison and Probation Service 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 17 January 2025. 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 his family, HMP Elmley and Oxleas NHS Foundation Trust . 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. 25 November 2024 Signature Catherine Wood Area Coroner for Mid Kent and Medway
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
16 January 2025
Catherine Wood
Mid Kent and Medway Coroners' Service
Oakwood House
Oakwood Park
Maidstone
Kent
ME16 8AE
Dear Ms Wood,
Thank you for your Regulation 28 report of 25 November 2024 following the inquest into the
death of Jonathon Paul Lawlor at HMP Elmley on 19 October 2023. 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 Lawlor’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 a concern regarding the delivery of key worker sessions provided at
HMP Elmley. Thank you for bringing your concerns to my attention.
In January 2024 I wrote to all Area Executive Directors, Prison Group Directors and
Governors setting out the HMPPS operational priorities for 2024/5 and the related core
expectations. One of these priorities was to increase the quantity and quality of regimes,
including key work, and to support this a new regime and business planning process has
been introduced.
The core expectations for key work delivery are that prisons must utilise all their allocated
resource for this task and that it must be profiled. Every prisoner must receive one key work
session every four weeks as a minimum, and any remaining resources must be targeted at
an enhanced offer for individual prisoners based on an assessment of risk, need and cohort
prioritisation.
Local action is also underway. The Custodial Manager who oversees keywork at HMP
Elmley has been compiling a Key Work Delivery Strategy to take forward as we move into
2025. This strategy details HMP Elmley’s plan to address and improve the issue of key work
within the establishment.
The goal is to ensure that all prisoners are allocated a dedicated key worker at the point
they are moved from the induction unit to a permanent houseblock. These key workers will
be staff from that particular houseblock to enable the building of better relationships
between the staff member and prisoner and enable the prisoner to feel they have a trusted
point of contact on the unit, giving them confidence to speak to their key worker about any
sensitive subjects that may arise. For continuity, if after being allocated a key worker a
prisoner is moved from one houseblock to another the key worker allocation will not change
HMP Elmley recognise that specific cohorts of prisoners are either more at risk of harm or
self-harm or are more vulnerable than others to incidences such as bullying. To manage
this risk certain staff members have been identified and will work specifically with these
cohorts, the aim being to have these staff upskilled in the areas that they are allocated to so
they can help these individuals and lower the: violence, self-harm, non-compliance and
bullying rates within the establishment. We currently have a member of staff from each
houseblock dedicated to young offenders with the aim of increasing these dedicated
cohorts over the coming months. Additional key work is also offered to those that reside on
our neurodiverse landing and key work is offered each weekend within the in-patient
department (IPD) and the Care and Separation Unit (CSU).
Key work is one of the core priorities for HMPPS in 2025/26. The expectation will be that
key work delivery will increase in this cycle of regime planning, aligned to each
establishment Regime Management Plan. Additional elements have been added to the
Regime Planning Template to enable establishments in their key work delivery.
For 2025/6 the minimum expectation for key work delivery will rise to two key work sessions
every four weeks as a minimum.
I hope the measures outlined above provide you with reassurance that learning and
appropriate action has been taken from the circumstances of Mr Lawlor’s death.
Yours sincerely
Director General Operations
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