Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0038, written 22 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jan 2025 |
|---|---|
| Reference | 2025-0038 |
| Deceased | Nathan Shepherd |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Suicide (from 2015) · 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: Ministry of Justice 1 CORONER I am Alison Mutch , senior coroner, for the coroner area of Manchester South 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 17th January 2024 I commenced an investigation into the death of Nathan Harry SHEPHERD. The investigation concluded at the end of the inquest on 20th December2024. The conclusion of the inquest was suicide and the medical cause of death was 1a) Hypoxic brain injury 1b) Hanging. 4 CIRCUMSTANCES OF THE DEATH Nathan Harry Shepherd had a history of mental health issues and drug use. Whilst in custody in 2023 he was subject to an ACCT following him taking an excess amount of medication in his cell. His calls were recorded from June 2023 and indicated he was using drugs and that his mental health fluctuated. On 8th January 2024 he was released from custody to approved premises at Ascot House. He was allocated a single room at Ascot House, he did not indicate any immediate thoughts of suicide or self-harm to staff. The full extent of his mental health history and ACCT history was not known to the staff at Ascot House. This was due to poor information sharing by probation service staff, this probably did not contribute to his death. On 11th January 2024 he sent a series of messages to other residents which demonstrated he was deteriorating. Staff were unaware of those messages. Ascot House overnight was staffed by one member of probation and an agency worker. Both were required to be first aid trained. On 11th January a text message was sent by Nathan Shepherd to the landline in the office at Ascot House. It caused the phone to ring and the message said the door was blocked and he was hanging. It was acted on by the member of staff going straight to Nathan Shepherd's room. An attempt to gain entry was unsuccessful because he had barricaded himself into the room. The barricading of entry to the room was made possible because the furniture was moveable. Attempts were made to force entry. After approximately 12 and a half minutes, entry was gained, and Nathan Shepherd was found suspended from a ligature. Entry would have been gained immediately had he not been able to barricade himself into his room. The staff cut the ligature on entry releasing the compression and began CPR. Paramedic assistance arrived approximately within 10 minutes after the staff gained entry. CPR continued along with attempts to intubate him. Intubation was unsuccessful until the arrival of a critical care paramedic. Successful intubation was followed by a return of spontaneous circulation at 06:38. He was transported to Stepping Hill Hospital where a CT scan 08:35 showed extensive loss of grey-white matter differentiation indicating an anoxic brain injury. He was moved to the critical care unit. On 15th January a further scan showed that the position had deteriorated further and he had a hypoxic brain injury that was not compatible with life. He died at Stepping Hill Hospital on 16th January 2024. 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 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. – 1. The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at Approved Premises. This meant that staff did not have training on how to deal with a situation. The inquest was told that the Probation Service were now developing such a policy but it had not been signed off or rolled out to staff. 2. A copy of the draft policy was available to the inquest but it was unclear what if any discussion there had been with Police Forces and how it would link in with Police policies such as the GMP Right Care Policy. 3. The evidence before the inquest was that Mr Shepherd was able to barricade himself with relative ease due to the mobility of the furniture in his room. The Approved Premises had no clear policy regarding furniture which meant that furniture could be used to create a barricade with relative ease. 4. The was a ligature point. Such ligature points remained in the Approved premises. It was unclear if changes could be made to reduce the risk they presented. 5. Agency staff were used under a national contract. The evidence before the inquest was that at the time of Mr Shepherd’s death there was no policy for ensuring they could deliver CPR / First Aid. It was part of the national contract that they should be so trained but there were no checks to ensure that this part of the contract was being followed. The evidence at the inquest was that the agency worker in place on the night did not appear able to deliver CPR. 6. Evidence from Probation and Prison staff showed a lack of understanding of how the prison system could update the probation system and where that information could be found. This meant that key information was not shared effectively creating a risk that probation staff in the community would not have a full picture of risk. 7. The inquest heard evidence that the information shared with the Approved Premises staff by other probation staff was not accurate and did not give a full picture of risk. This was in part due to the fact that it appeared key documents were being regularly completed by probation staff who were not the allocated probation officer and so were unfamiliar with the history. 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 19th March 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 mother of Mr Shepherd on behalf of the family. I have also sent it to GMP, Prisons & Probation Ombudsman (PPO), HMP Berwyn & Probation Services who may find it useful or of interest. 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. They may send a copy of this report to any person who they believe 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 Alison Mutch HM Senior Coroner 22/01/2025
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.
HMPPS National Approved Premises Team Floor 8.38 102 Petty France London SW1H 9EA E: 27th June 2025 Alison Mutch OBE HM Senior Coroner Manchester South By email only to: Dear Madam, Inquest Touching the Death of Nathan Harry Shepherd I refer to your Regulation 28 Report following the Inquest into the death of Mr. Shepherd and am issuing this response on behalf of the Ministry of Justice. I know that you will share a copy of this response with his family, and I would like to take this opportunity to express my sincere condolences for their loss. 1. The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at Approved Premises. This meant that staff did not have training on how to deal with a situation. The inquest was told that the Probation Service were now developing such a policy but it had not been signed off or rolled out to staff. The Barricade Guidance referred to in evidence given at the Inquest hearing has now been finalised and is going through the final stages of sign off prior to issue to all approved premises staff on 1st August 2025. This guidance will form part of the Safe Working Practice document and staff will be required to acknowledge receipt and their understanding by the end of September 2025. This will be overseen by all Approved Premises Managers. 2. A copy of the draft policy was available to the inquest but it was unclear what if any discussion there had been with Police Forces and how it would link in with Police policies such as the GMP Right Care Policy The Ministry of Justice is not currently a party to the National Partnership Agreement which supports working together to ensure people get the right support. At a local level your concern has been raised with Greater Manchester Police. 3. The evidence before the inquest was that Mr Shepherd was able to barricade himself with relative ease due to the mobility of the furniture in his room. The Approved Premises had no clear policy regarding furniture which meant that furniture could be used to create a barricade with relative ease. The policy on furniture in Approved Premises is set out in a furniture specification which states that beds and wardrobes should be fixed (although this does not apply to chairs). This specification is currently being applied across all Approved Premises but it is acknowledged that this is a rolling programme and is subject to funding for renovation programmes. The Probation Estates Team are currently collating information on furniture through local estates boards and every effort will be made to prioritise funding to replace moveable furniture with fixed furniture. 4. The ceiling fire detection equipment was a ligature point. Such ligature points remained in the Approved premises. It was unclear if changes could be made to reduce the risk they presented. Fire detection equipment that is designed to meet anti-ligature standards is available and is being introduced across the Approved Premises estate. Facilities Management providers are aware of the need for any replacement fittings to meet the anti ligature standards. In light of your concern this has now been raised with the AP Maintenance Strategy Group to undertake a review of existing equipment with a view to ensuring this replacement work is incorporated into future maintenance programmes 5. Agency staff were used under a national contract. The evidence before the inquest was that at the time of Mr Shepherd’s death there was no policy for ensuring they could deliver CPR / First Aid. It was part of the national contract that they should be so trained but there were no checks to ensure that this part of the contract was being followed. The evidence at the inquest was that the agency worker in place on the night did not appear able to deliver CPR. The Double Waking Night Cover contract with external agencies is due to come to an end in March 2026 and thereafter night shifts at Approved Premises will no longer be contracted out and will be brough in house. This will ensure that all staff will be trained in accordance with HMPPS requirements, which includes First Aid, CPR and use of the defibrillator. There are already pilots in place across the country working to this new arrangement. Where this service is still being delivered by external agencies, it will be part of the contract management process to monitor compliance with the contractual term that requires the agency staff to be fully trained to the standard required by HMPPS. 6. Evidence from Probation and Prison staff showed a lack of understanding of how the prison system could update the probation system and where that information could be found. This meant that key information was not shared effectively creating a risk that probation staff in the community would not have a full picture of risk. There is now a new digital referral process in place that pulls information from both prison and probation systems as part of the referral process, allowing for much more accurate and timely sharing of information. The information is pulled directly from CNOMIS into a live referral document and this is reviewed by the practitioner and also the AP Manager who assesses the referral. The information includes custodial behaviour and issues around suicide and self harm risk. 7. The inquest heard evidence that the information shared with the Approved Premises staff by other probation staff was not accurate and did not give a full picture of risk. This was in part due to the fact that it appeared key documents were being regularly completed by probation staff who were not the allocated probation officer and so were unfamiliar with the history. Oasys is an assessment tool used by a Probation Practitioner to assess risk. The new digital referral system pulls information from Oasys directly into the form. It also brings in information from NDelius and CNOMIS. This allows for much more accurate information to be submitted for viewing by the AP Manager and staff. 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. Yours sincerely, Head of the National Approved Premises Team
See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.