Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2025-0047, written 3 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Dec 2024 |
|---|---|
| Reference | 2025-0047 |
| Deceased | Paul Gobell |
| Coroner | Simon Burge |
| Coroner area | Nottingham City and Nottinghamshire |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 - MOJ
2 HM Inspectorate of Prisons
3 Chief Coroners Office for PFD's
1
CORONER
I am Simon BURGE, Assistant Coroner for the coroner area of Nottingham City and
Nottinghamshire
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 18 November 2021 I commenced an investigation into the death of Paul Martin GOBELL
aged 59. The investigation concluded at the end of the inquest on 18 November 2024. The
conclusion of the inquest was that:
See attached
4
CIRCUMSTANCES OF THE DEATH
See attached
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)
1. Paul Gobell was serving a life sentence for rape. He had served fifteen years in a closed
prison, most recently at HM Prison, Whatton. In August 2021, he was deemed by the Parole
Board to be suitable for a move to open conditions and was therefore transferred to HM
Prison Hollesley Bay on 20/10/21. He was there for just two and a half weeks. Within a few
hours of his return to HM Prison, Whatton on 04/11/21 he was subject to a Control &
Restraint incident. His behaviour at this time was reported to be refractory and aggressive.
During the incident he received a soft tissue injury which necessitated a trip to the A&E
department at the local hospital. As a result, the usual First Night Interview did not take
place that evening, nor on the following day. As a result there was no welfare check and no
ACCT was opened. There is no national or local policy in place stating what arrangements
should be made to carry out a welfare check when, for operational reasons, the First Night
Interview cannot take place.
2. Paul Gobell was assessed as being suitable to share a cell in June 2021, having
previously been considered high risk. He was not informed off this change until immediately
prior to the C&R incident on 04/11/21 and had never had to share a cell before. The Cell
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
Sharing Risk Assessment carried out by Healthcare and Reception staff upon his return to
HM Prison, Whatton on 04/11/21 deemed him to be a standard risk. He felt that he should
have been designated as high risk. He was concerned for the safety of whoever he might be
required to share a cell with, due to the fact that he (Gobell) suffered from parasomnia.
Despite protesting to staff, he was told that he would have to share and it was this that
sparked the incident leading to the use of control and restraint techniques. Had he been
pre-warned of the change to his cell sharing status this incident would not have happened.
Consideration should be given to ensuring that any such change of cell sharing risk is
communicated promptly to the prisoner concerned.
3. Whilst at HM Prison, Hollesley Bay, Paul Gobell rang the Probation Officer (who had dealt
with his Parole Board hearing in August 2021) and told her that he felt he was a poor fit in
open conditions, that the environment there was hostile and unpleasant and that he had let
slip to another prisoner that he was serving a term of imprisonment for offences of a sexual
nature. The Probation Officer concerned did not see fit to report these disclosures to the
Offender Management Unit. An Open Conditions Suitability Assessment ('OCSA') was
subsequently held at HM Prison, Hollesley Bay on 02/11/24, after Mr. Gobell spoke to an
Orderly Officer and asked to be returned to HM Prison, Whatton. Despite the multi-
disciplinary nature of the OCSA, no input was obtained or requested from Probation staff at
HM Prison, Hollesley Bay or elsewhere. Had the relevant Probation staff been involved this
would have better informed the OCSA and steps could have been taken to offer Mr. Gobell
additional support, designed to encourage him to remain in the open conditions of a 'D'
category prison rather than taking the regressive step of being returned to closed
conditions. Consideration should be given to imposing a requirement that the input of
Probation (both from the Offender Management Unit and outside) is obtained whenever a
OCSA is undertaken.
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 January 22, 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.
COPIES and PUBLICATION
8
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons
Practice Plus Group LIMITED
I have also sent it to
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
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
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: 03/12/2024
Simon BURGE
Assistant Coroner for
Nottingham City and Nottinghamshire
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
2 responses 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.
HM INSPECTORATE OF PRISONS
3rd floor
10 South Colonnade
Canary Wharf
London E14 4PU
E-mail:
Tel:
17 January 2025
HM Chief Inspector of Prisons
Simon Burge
Assistant Coroner
Nottingham City Council
Council House
Old Market Square
Nottingham
NG1 2DT
Dear Mr. Burge,
Paul Martin GOBELL – Prevention of Future Deaths Report
Thank you for sharing your regulation 28 report to prevent future deaths with His Majesty’s
Inspectorate of Prisons (HMI Prisons). We are saddened to learn of the findings of your
investigation.
HMI Prisons is an independent inspectorate. We provide scrutiny of the conditions for and
treatment of prisoners and other detainees and report publicly on our findings.
HMI Prisons’ inspections are carried out against published inspection criteria known as
Expectations. The Inspectorate sets its own inspection criteria to ensure transparency and
independence. Many of the issues highlighted in your report are covered via our
Expectations, and therefore matters which our inspectors will consider on each inspection.
For example, in relation to first night interviews, one of our safety expectations states:
“Prisoners are safe and treated with respect on their reception and first night in prison. Risks
are identified and prisoners are supported according to their individual needs.”
Other issues raised in your report such as the importance of prisoners being appropriately
and safely located, the need for these decisions to be conveyed to prisoners, and the
importance of prisoners being held in the appropriate security conditions, with all relevant
departments involved in reviews, are also covered via our Expectations.
Where we identify concerns that need to be addressed by leaders and followed up by
inspectors at the next inspection or independent review of progress, these are set out in our
published reports. In line with agreed protocols, inspected prisons then provide an action
plan three months after publication of the report.
17/01/25
www.justiceinspectorates.gov.uk/hmiprisons
We will keep your findings on file so that, when we next inspect HMP Whatton and HMP
Hollesley Bay, inspectors are aware of this information and can follow up as appropriate.
For completeness, it would also be helpful if your office could please share the circumstances
of the death, which we understand are set out in a separate attachment.
Yours sincerely,
17/01/25
www.justiceinspectorates.gov.uk/hmiprisons
Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email: 20 January 2025 Mr. Simon Burge HM Assistant Coroner Nottingham City and Nottinghamshire Nottingham City Council Council House Old Market Square Nottingham NG1 2DT Dear Mr Burge, Thank you for your Regulation 28 report of 3 December 2024 following the inquest into the death of Paul Gobell at HMP Whatton, which was sent to the Ministry of Justice. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations. I know that you will share a copy of this response with Mr Gobell’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 concerns regarding welfare checks when the first night interview cannot take place, communicating changes to Cell Sharing Risk Assessments (CSRA) to prisoners and the involvement of probation whenever an Open Conditions Suitability Assessment (OCSA) is undertaken. All prisons have well established first night induction processes and policies in place to ensure that prisoners receive appropriate care when entering prison custody. Welfare checks and conversations form part of this process and, in most cases, prisoners coming into reception are inducted in line with existing national and local policies. However, there may be exceptional circumstances when this does not happen, such as in the situation you have described involving Mr Gobell. HMP Whatton will update their Induction policy so that, when a normal induction cannot be facilitated, the prisoner will be asked to complete the “late arrivals form.” This form asks the prisoner to provide information that can then be used to consider the prisoner’s welfare until a face-to-face interview can be conducted. The HMPPS CSRA policy is currently under review and is due to be reissued during 2025. As part of this review, we will ensure that the need to inform prisoners as soon as possible of changes to their CSRA status is made clear. In support of this HMP Whatton have amended their local safety strategy to now include the line Prisoners must be informed in writing when their CSRA levels change following a CSRA review. HMP Hollesley Bay have provided assurance that wherever possible (for example where an immediate OCSA for public protection reasons is not required) they will seek Prison Offender Manager (POM) attendance at local stability meetings where OCSAs are being discussed. 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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