Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0133, written 11 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Mar 2025 |
|---|---|
| Reference | 2025-0133 |
| Deceased | Sean Higgins |
| Coroner | Patricia Harding |
| Coroner area | Mid Kent and Medway |
| Category | State Custody related deaths · Mental Health 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.
Appendix 16.1 – Templates for PDF reports REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. THE GOVERNOR HMP ROCHESTER 1 CORONER I am Patricia Harding, senior coroner, for the coroner area of 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. 3 INVESTIGATION and INQUEST On 16th February 2024 I commenced an investigation into the death of Sean Higgins 45 years. The investigation concluded at the end of the inquest on 17th February 2025. The conclusion of the inquest was suicide, the medical cause of death1a Suspension CIRCUMSTANCES OF THE DEATH 4 Sean Higgins had a long history of mental health issues and substance abuse. His exact diagnosis was a ma(cid:425)er of differing opinion between clinicians but alterna(cid:415)ve diagnoses included paranoid schizophrenia, drug induced psychosis and personality disorder for which he was prescribed an(cid:415)psycho(cid:415)c and an(cid:415)-anxiety medica(cid:415)on. In 2019 he was sentenced to 12 years imprisonment and in 2021 he was transferred to HMP Rochester. Between September 2022 and August 2023 he had been placed on ACCT procedures on five previous occasions whilst at HMP Rochester a(cid:332)er concerns of self-harm were raised including a(cid:332)er making ligatures. The inquest inves(cid:415)gated the last few months of his life when he finished psychological therapy and was removed from the mental health team’s caseload. Coincident with this but not apparently because of it he started to self isolate and was managed under CSIP procedures. In December 2023 he stopped taking his medica(cid:415)on. His mental health deteriorated. In early January 2024 an ACCT was opened when the deceased was discovered with a . The ACCT remained open for the whole of January, ligature with six reviews being held. The mental health team did not a(cid:425)end any of the reviews, although they provided a verbal contribu(cid:415)on for one which did not contain relevant informa(cid:415)on from which an accurate risk assessment could be made. The ACCT was closed without the support ac(cid:415)ons being completed (which included the prisoner engaging with the mental health team) and without considera(cid:415)on of the available documenta(cid:415)on. The Custodial Manager and supervising officer on the wing who were responsible for closing the ACCT had been sent emails echoing that which was in the ongoing record that the deceased was hallucina(cid:415)ng and was talking of hanging himself which they had not read. There were mul(cid:415)ple failures follow policies for both the prison and mental health staff. The deceased fashioned a ligature six days later and le(cid:332) a note sta(cid:415)ng his mental health was torture. He had not received medica(cid:415)on for 45 days and had not seen anyone from the mental health team for over two months. 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) Although HMP Rochester had addressed many of the concerns raised by the PPO in advance of the inquest, evidence was given at the inquest that some officers chairing reviews did not read relevant documentation beyond the last ACCT review prior to the review taking place. Although they additionally looked at the last CSIP review where the processes were running in tandem, they did not read the ongoing record or Nomis case notes and were unable to conduct an accurate assessment of risk as a result (2) Some of the officers chairing reviews did not understand how to complete the support plan paperwork such that the ACCT was closed when some of the support plans had not started or had not been completed 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Governor HMP Rochester 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 7th May 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: family’s legal representatives, Oxleas NHS Foundation Trust. I have also sent it to Prison & Probation Ombudsman 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 other 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. 9 11th March 2025 Patricia Harding HM Senior Coroner Mid Kent & 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 of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email: Senior Coroner Patricia Harding Mid Kent and Medway Coroners’ Service Oakwood House Oakwood Park Maidstone ME16 8AE 06 April 2025 Dear Ms Harding, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Thank you for your Regulation 28 report of 11 March 2025 following the inquest into the death of Sean Higgins at HMP Rochester, 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 Higgins family, and I would firstly 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 the Assessment, Care in Custody and Teamwork (ACCT) case management procedures at Rochester, specifically around the accurate assessment of risk and the quality of support plans. The Governor of HMP Rochester has provided assurances that these issues have been addressed, and the establishment have produced a training video covering both areas of concern. This has been shared with case coordinators and their line managers and is intended to ensure there is a clear understanding of the process among those responsible for conducting ACCT reviews and developing support plans. To further embed understanding of existing procedures, HMP Rochester’s ’s Safety Team has conducted briefing sessions with all case coordinators, specifically focused on the concerns raised at the inquest. These sessions have been designed to reinforce the importance of thoroughly reviewing all relevant documentation, including ongoing case notes when assessing risk. They have also emphasised the need to create meaningful support plans that are actioned and fully implemented before initiating the closure of the ACCT. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action has been taken to address these matters. Yours sincerely, Director General of Operations
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