Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0378, written 25 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 | 25 Jul 2025 |
|---|---|
| Reference | 2025-0378 |
| Deceased | Michael Pugh |
| Coroner | Patricia Harding |
| Coroner area | Kent and Medway |
| Category | State Custody related deaths · Suicide (from 2015) |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Service Executive Director Public Sector Prisons South , His Majesty’s Prison and Probation CORONER I am Patricia Harding, senior coroner for the coroner area of Kent and Medway 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. 1 2 3 INVESTIGATION and INQUEST On 3rd July 2024 I commenced an investigation into the death of Michael Pugh, 29 years. The investigation concluded at the end of the inquest on 21st July2025. The conclusion of the inquest was suicide; Mr. Pugh having suspended himself in his cell at HMP Swaleside . 4 CIRCUMSTANCES OF THE DEATH Michael Pugh was found in his cell on 29th June 2024 having died. He was subject of an ACCT at the time of his death. It was determined at the last ACCT review before his death that he should be subject to hourly observations. Observations were carried out on the afternoon of 28th June 2024 but recorded incorrectly. No observations were carried out on 29th June 2024 between 07.22 and 09.57 when Mr. Pugh was discovered having died, but the ongoing record was completed retrospectively to show that they had been carried out 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 prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POELT training and the other 1 month experience. Both officers gave evidence that following their POELT training their understanding of the ACCT process was incomplete; one stating “observations were explained but I didn’t have a fair idea what to do or how to undergo the process”, another stating “I didn’t understand the importance of observing a prisoner at unpredictable times. Even though I was told the observations should be hourly it was not explained to me how to stagger timing. I misunderstood what was required of me in recording the details when I recorded them as having happened at 13.00, 14.00, 15.00 and 16.00. 6 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 19th 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mr. Pugh’s next of kin, Ministry of Justice, Oxleas NHS Foundation Trust. I have also sent it to Prison and 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 DATE 25TH July 2025 SIGNED BY CORONER Patricia Harding
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 Patricia Harding Senior Coroner for Kent and Medway Oakwood House Oakwood Park Maidstone Kent ME16 8AE 12 September 2025 Dear Ms Harding, Thank you for your Regulation 28 report of 25 July 2025 following the inquest into the death of Michael Pugh at HMP Swaleside on 29 June 2024. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the interim Director General of Operations. I know that you will share a copy of this response with Mr Pugh’s 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 expressed concern regarding the Assessment, Care in Custody and Teamwork (ACCT) training provided to new prison officers during their initial Prison Officer Entry Level Training (POELT). I would like to assure you that HMPPS are committed to providing prison officers with the right support, training and tools to empower them to do their jobs. All new members of staff receive a full day of training on suicide and self-harm prevention during their POELT training. This includes training on the ACCT process and the appropriate timings and intervals of when ACCT observations need to be carried out and recorded. Following completion of POELT training, new entry officers have a two week local induction before ‘going live’ and becoming fully operational. Part of this local induction programme at Swaleside includes ACCT upskilling and a session based on completion of ACCT documents and recording of ACCT observations. The local training team keep a record of these sessions. Any further training needs for staff would be identified and delivered locally. Additionally, any member of staff who undertakes a key role relating to ACCT case management, for example ACCT assessors or case co-ordinators, receives training specific to these roles. In addition to the training HMPPS has an online Safety Learning Reference Library which holds various guidance, templates and training material, all of which are accessible to all staff via the HMPPS intranet. The library includes an area dedicated to ACCT where staff can access a ‘Recording Observations’ video guide as well as a written guide, both of which include examples of best practice for carrying out ACCT observations. Going forward HMP Swaleside will promote the Safety Learning Reference Library to new members of staff during their induction and, furthermore, will signpost the Safety Learning Reference Library to all staff during the HMPPS annual national safety focus initiative being held next month. I hope the measures outlined above provide you with reassurance that learning and appropriate action has been taken following Mr Pugh’s death. Yours sincerely Director General Operations
See every Prevention of Future Deaths report matching Oxleas NHS Foundation Trust, 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.