Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0350, written 10 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jul 2025 |
|---|---|
| Reference | 2025-0350 |
| Deceased | Gavin Wheale |
| Coroner | Ian Dreelan |
| Coroner area | Birmingham and Solihull |
| Category | Alcohol, drug and medication related deaths · 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.
1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HM Prison & Probation Service CORONER I am Ian Dreelan, Assistant Coroner for Birmingham and Solihull 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. INVESTIGATION and INQUEST On 15 August 2024 I commenced an investigation into the death of Gavin James WHEALE. The investigation concluded at the end of the inquest. The conclusion of the inquest was; It is the unanimous opinion of the Jury that Mr Wheale did die due to mixed drug interactions additionally, the events examined in this inquest highlight shortcomings in the following areas at the time of Mr Wheale's death: 1. The training of custodial and medical staff at HMP Birmingham in the implementation of policies and procedures designed to facilitate the arrival, processing and housing of prisoners considered 'at risk' or vulnerable. This had no impact on Mr Wheale's death. 2. The lines of communication across custodial staff at HMP Birmingham concerning the effective transfer of information pertinent to the health and wellbeing of incoming prisoners This had no impact on Mr Wheale's death. 3. The Lines of communication between medical and custodial staff at HMP Birmingham concerning the effective transfer of information pertinent to the health and wellbeing of incoming prisoners. This had no impact on Mr Wheale's death. 4. The facilities and resources in the reception area at HMP Birmingham pertaining to custodial staff's ability to monitor and supervise incoming prisoners, particularly those considered 'at risk' or vulnerable. This had no impact on Mr Wheale's death. Conclusion of the Jury as to the death: Drug Related. CIRCUMSTANCES OF THE DEATH On 6/8/24, Gavin James Wheale was arrested on a recall to prison. He remained under constant supervision and handcuffed as he was suspected to be concealing an item. He was then transported by GeoAmey on 7/8/24 to HMP Birmingham. At 12.45, Mr Wheale was handed to HMP staff, where he was no longer handcuffed or under constant supervision. Mr Wheale provided a urine sample that tested positive for cocaine, benzodiazepines, cannabinoids and opiates. He began the body scanner process at 16.00 on 7/8/24, which came back as inconclusive. A short time later, Mr Wheale was seen waving a plastic bag in the air, which was empty, but said it had contained Diazepam, and he had taken it. He was then placed in a holding cell in the Care and Separation Unit (CSU). At 14.26 on 8/824, Mr Wheale was found unresponsive in his CSU cell. He was pronounced dead at 14.39. Following a post mortem, the medical cause of death was determined to be: 1a Mixed drug interactions (Morphine, Cocaine and Diazepam) 1b 1c 1d II 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. – 1. At the time Mr Wheale resided in HMP Birmingham, HMP Birmingham Secreted Item Policy (January 2020) was in force. An updated policy was issued after Mr Wheale’s death (dated Aug 2024). Both versions of the policy accept that ‘There is a clear risk to a prisoner’s health when an item is secreted internally’. My concern is that focus of the policy is the prevention of contraband entering the prison system and therefore it presupposes the outcome of the secreted item(s) being surrendered or disposed of by the prisoner. It does not provide clear guidance to staff on a situation, as with Mr Wheale, where an item previously concealed is then claimed to have been (or indeed a situation where it was witnessed to have been) removed and ingested without its previous packaging. 2. Evidence was heard from WMP and GEOAmey staff dealing with their required procedures where a person in their custody, in this instance Mr Wheale, was known or suspected of concealing items; both organisations required constant supervision and handcuffing. My concern is that upon handover to HMP Birmingham prisoners who have previously been under constant supervision, with their movement restricted, enter a regime with no equivalent levels of monitoring rendering HMP Birmingham unable to fully discharge their duty of care to that prisoner. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths, and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4 September 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 5 6 7 8 Prison & Probation Ombudsman HM Inspectorate of Prisons Independent Advisory Panel on Deaths in Custody 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. She may send a copy of this report to any person who she 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. 10 July 2025 9 Signature: Ian Dreelan Assistant Coroner for Birmingham and Solihull
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.
Interim Director General of
Operations
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London
SW1H 9AJ
04 September 2025
Ian Dreelan
Assistant Coroner for Birmingham
and Solihull
50 Newton Street
Birmingham
B4 6NE
Dear Mr Dreelan
Thank you for your Regulation 28 report of 10 July 2025 following the inquest into the death
of Gavin Wheale at HMP Birmingham on 8 August 2024. 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 Wheale’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.
The first concern you raise relates to HMP Birmingham’s Secreted Items Policy and its
focus on preventing contraband from entering the prison system. I can confirm that following
the inquest the prison has committed to updating the local policy to include clear guidance
for staff on the action they need to take where it is suspected that a prisoner has ingested
an item. The guidance will cover steps such as notifying healthcare, initiating appropriate
observations, and considering whether suicide and self-harm procedures should be
opened. Additionally, the West Midlands Group Safety Lead will ensure that consistent
guidance is implemented across all establishments within their regional area.
You also raise a concern regarding the management of prisoners who enter the prison on
high levels of monitoring. In response to this, HMP Birmingham will be issuing guidance to
staff to ensure that a fully documented risk assessment is completed for any prisoner
entering the establishment under constant supervision, whether due to secreted items or
other reasons - to ensure that the individual is managed effectively and safely, clearly
documenting the actions to be taken to manage any associated risks.
I hope the measures outlined above provide you with reassurance that learning and
appropriate action is being taken to address the issues you have identified from the
circumstances of Mr Wheale’s death.
Yours sincerely
Interim Director General Operations
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