Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2025-0419, written 15 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Dec 2023 |
|---|---|
| Reference | 2025-0419 |
| Deceased | Peter Kelly |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | Police 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.
MS N J MUNDY
H M CORONER
SOUTH YORKSHIRE (East District)
email:
CORONER'S COURT AND OFFICE
CROWN COURT
COLLEGE ROAD
DONCASTER DN1 3HS
Tel: (01302) 737135
Fax: (01302) 736365
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. CORONER
, Chief Constable South Yorkshire Police
I am Ms N J Mundy, Senior Coroner, for South Yorkshire, East District
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3. INVESTIGATION and INQUEST
On the 16th May 2023 I commenced an investigation into the death of Peter Alfred Kelly. The
investigation concluded at the end of the inquest on the 16th November 2023 . The conclusion of the
inquest was:
4. CIRCUMSTANCES OF THE DEATH
Mr Kelly was taken into police custody on the evening of the 25th April 2023 following an assault
whilst inebriated. He was placed in a cell, observed through the night and in the morning deemed fit
enough for interview. The interview proceeded after which a decision was made that there was no
legal basis upon which he could be detained further from an investigative point of view and thus
arrangements were made for his release from custody.
The custody officer releasing Mr Kelly and who completed the Pre Release Risk Assessment noted
that Mr Kelly stated to have mental health issues which were treated with sertraline. There is a
question on that form which states "how are you feeling now" but this was left blank. In evidence the
officer stated that he considered Mr Kelly's demeanour to be jovial, he caused no difficulties whilst in
police custody, he did not feel that he was in crisis and felt that he was fit for release. However,
whilst giving evidence he expanded on these comments by stating that he believed that Mr Kelly
should have been seen by a health professional while in custody, he referred to having a Liaison and
Diversion team and that he felt that the opportunity for them to assess was missed. He indicated
that Mr Kelly had been dealt with "very fast" in custody that day and he assumed Mr Kelly was let
out "too quick" he suggested that South Yorkshire Police missed an opportunity and that there are
procedures in place and thus he feels that the organisation let Mr Kelly down, potentially. He
informed me that the Liaison and Diversion team would check their own computers to see who they
wanted to assess and then come down and assess them and he speculated that the team may not
have got round to him because he was released too quickly. Furthermore, he considered that the
reference to depression and self harm on the assessments that took place in custody should have
triggered a review by a mental health professional. .
The Inquest was suspended pending obtaining further information and resumed where evidence was
provided from both the Liaison and Diversion team and in relation a professional standards referral.
Accepted the evidence provided by the LND team which was essentially that the computer records
they have access to merely list those that are in police custody, their name and the reason for their
arrest and does not include any detail regarding mental health. There is space for officers to put
LND in the margin which means that an assessment is being requested. However, many requests
for assessment are made by those working in the custody suite contacting the LND directly by phone
to express any concerns and to ask for an assessment.
Following this risk assessment Mr Kelly was released on the morning of the 26th April. Mr Kelly was
found hanged at 07:45 on the 27th April and it was believed he had been dead for some time.
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 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. Failure of a custody sergeant to understand the processes for involving Liaison and Diversion
team.
2. Lack of knowledge regarding the information that is available to the liaison and diversion team on
the police connect system and the facility for police officers to enter LND on that system as a flag.
3. Failure to properly complete the Pre Release risk assessment and failure to understand the
importance of the question asking an individual how they are feeling at the point of release.
4. A lack of understanding as to the triggers which may lead to contact with LND not just during a
person's time whilst held in custody but at the point of release.
5. It appears that there is a training need for those working within the custody suite to understand
how the system works with LND and the importance of adequately addressing those who are
potentially vulnerable with regard to their mental health at the point of discharge.
6. ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you, Lauren Poultney
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 the
9th February 2024. 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 Person:
.
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. 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 by the Chief Coroner.
15 December 2023
Ms N J Mundy, LL.B (hons)
for South Yorkshire East
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.
FAO Ms Mundy HM Coroner South Yorkshire (East District) PRIVATE Your Ref: Our Ref: Date: 13 May 2024 Dear Ms Mundy Inquest touching upon the death of Mr Peter Alfred Kelly I write in response to the Regulation 28 Report to Prevent Future Deaths dated 15 December 2023. Your report raised the following Matters of Concern: 1. Failure of a custody sergeant to understand the processes for involving Liaison and Diversion team. 2. Lack of knowledge regarding the information that is available to the Liaison and Diversion team on the police connect system and the facility for police officers to enter LND on that system as a flag. 3. Failure to properly complete the Pre-Release Risk Assessment and failure to understand the importance of the question asking an individual how they are feeling at the point of release. 4. A lack of understanding as to the triggers which may lead to contact with LND not just during a person's time whilst held in custody but at the point of release. 5. It appears that there is a training need for those working within the custody suite to understand how the system works with LND and the importance of adequately addressing those who are potentially vulnerable with regard to their mental health at the point of discharge. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: For Sat. Navigation users S9 2EG E-Mail: Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: Page 1 Response to Matters of Concern Custody Process Overview PRIVATE The process of involving Liaison and Diversion (LND/L&D) within custody is one that has been embedded within each of the three custody suites within South Yorkshire for the last 10 years. Liaison and Diversion staff are based at all three suites on a daily basis with face to face contact and phone contact, Monday to Friday 7am-7pm and 7am-3pm on weekends and Bank Holidays with an out of hours referral process available outside of these times. The initial process would involve a detainee being arrested and brought into police detention and presented before a Custody Sergeant with the following steps taken: Commencement and completion of risk assessments (RA), both a self-assessment by the Custody Sergeant with the detainee and an officer assessment is completed by the Custody Sergeant. Any requirement for Liaison and Diversion identified by the Custody Sergeant is identified by adding a requirement for “L&D” flag on the visible remarks section of the CONNECT custody page or by direct face to face communication and / or by telephone. CONNECT is the crime system used by South Yorkshire Police. Liaison and Diversion are able to view the “L&D” flag to identify that an assessment is required by the Custody Sergeant. Liaison and Diversion are able to review the completed risk assessments on CONNECT before checking their own systems. Liaison and Diversion complete their own review of other detainees in custody on the CONNECT system to identify those that may also need assessment, but this is subject to priorities already identified and resources/demands. Liaison and Diversion would complete identified assessments with the detainee within custody, update the CONNECT system with a log entry and update the Custody Sergeant to confirm that they have been seen. At any time during police detention and continuing RA it becomes apparent to a Custody Sergeant that a detainee requires or requests the service of “L&D” then the above process is followed. At any time during police detention and continuing RA it becomes apparent that a detainee requires or requests the service of a Health Care Professional (HCP), a medical call out will be completed on CONNECT with HCP based 24/7 within all three custody suites. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: For Sat. Navigation users S9 2EG E-Mail: Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: 0 Page 2 PRIVATE If for any reason given resourcing, demands and timeliness, a detainee has been identified by Liaison and Diversion but cannot be assessed, a letter would be sent to the detainee if they would like to engage with services. If for any reason given resourcing, demands and timeliness, a detainee has been identified by a Custody Sergeant and /or Liaison and Diversion a self-referral process is available to be completed by the Custody Sergeant should the detainee agree/consent to this. If prior to release it becomes apparent to a Custody Sergeant that a detainee is not fit for release, then the service of a HCP can be requested to complete an assessment as to fitness for release with a medical call out completed on CONNECT. At the point of release a Custody Sergeant will complete a Pre Release Risk Assessment (PRA) with the detainee and if it is identified at that point that they are not fit for release and or require “L&D” then either a self-referral can be completed if agreed by the detainee or a fitness for release requested. At the point of release and completion of the PRA by the Custody Sergeant the detainee is identified as fit for release then they are released. There are five Matters of Concern that have been raised by the Coroner, these being: 1. Failure of a custody sergeant to understand the processes for involving Liaison and Diversion team. Custody Sergeant B provided evidence to the Coroner and identified that PK should have been seen by a HCP. Custody Sergeant B was aware of having a Liaison and Diversion team and felt that the opportunity to assess had been missed. The custody record and the initial RA completed by Custody Sergeant A identified a number of triggers that would have necessitated an assessment by the Liaison Diversion Team:- Can’t read or write. Mental health issues - depression Medication for mental health issues - Sertraline Self-harm- 3 weeks previous by cutting. Consuming alcohol - 2 bottles of whiskey and 12 Cans Taken any drugs- Cocaine. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: For Sat. Navigation users S9 2EG E-Mail: Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: Page 3 PRIVATE These triggers were acknowledged by both Custody Sergeant A and Custody Sergeant B and should have instigated an assessment by Liaison and Diversion at the point of booking in and handover, but this was not completed. The issue raised by Custody Sergeant B was that PK was dealt with “very fast” and let out “too quick”, however PK was in custody for 12hrs 40 minutes. Had both Custody Sergeant A and B instigated an assessment at the earliest opportunity of booking in and/or handover this would not have been an issue. All Custody Sergeants are provided with input around the Liaison and Diversion Team as part of their initial training, this is delivered by a Police Sergeant / Custody Sergeant jointly with Liaison and Diversion and covers the following areas:- RA and the formulation of care plans PRA What is Healthcare in a police custody setting (Leeds NHS) – Subject Matter Expert (SME) delivered by a current custody HCP Liaison and Diversion specific input – Subject Matter Expert (SME) delivered by L&D practitioners. The initial training is also supported by available online CPD circulated and made available to Custody Sergeants; the area covered in March 2024 was PRA. Action: There is to be further clarification circulated to all Custody Sergeants and custody staff around the triggers and priorities for involving Liaison and Diversion, a flowchart will be provided by Liaison and Diversion and placed at each booking in desk for every Custody Sergeant to visually refer to when completing RA and PRA all three suites. This is to be in place and completed by the 31st May 2024 2. Lack of knowledge regarding the information that is available to the Liaison and Diversion team on the police connect system and the facility for police officers to enter LND on that system as a flag. Custody Sergeant B provided evidence that Liaison and Diversion would check their own computers to see who they wanted to assess and may not have got round to PK because he was released too quickly. Liaison and Diversion provided evidence which essentially identified that the computer records they have access to merely lists those in police custody, their name and the reason for their arrest and does not include any detail regarding mental health, and it is also identified that many requests for assessments are by phone so there is no visual record. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: For Sat. Navigation users S9 2EG E-Mail: Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: Page 4 PRIVATE The CONNECT system does not provide any barriers to police officers entering ‘ L&D’ as a flag to allow Liaison and Diversion to identify and prioritise those identified by Custody Sergeants at any point of detention, both Custody Sergeants A & B are aware of the L&D flag and how to add this but neither chose to do this ( as in 1 above) and therefore preventing Liaison and Diversion in both identifying and prioritising. Custody Sergeant A has identified that it would be better for PK to be assessed in the morning so has not entered the flag, Custody Sergeant B has not indicated why they did not feel it necessary to enter the flag although does state and indicates in evidence that it was left to Liaison and Diversion to identify and see who they wanted to assess. The evidence provided by Liaison and Diversion does not identify that their team have access to the full Risk Assessment completed by the Custody Sergeants so would have been able to see the triggers identified, should this have been identified by either Custody Sergeants A or B by the ‘ L&D’ flag, or indeed it could have been identified directly by Liaison and Diversion as thought by Custody Sergeant B, if sufficient time/resources had allowed, but it had not in these circumstances. Action: There will be further guidance circulated to all Liaison and Diversion staff that full access to the completed risk assessments on CONNECT is open and available to them. This is to be completed by the 31st May 2024. Action: There will be further guidance circulated to all Custody Sergeants around entering the “L&D” flag on the CONNECT system. This is to be completed by the 31st May 2024 this time frame to allow all staff to be made aware given the custody shift system. 3. Failure to properly complete the Pre-Release Risk Assessment and failure to understand the importance of the question asking an individual how they are feeling at the point of release. Custody Sergeant B provided evidence in relation to PK demeanour as jovial, caused no issues whilst in police custody, did not feel he was in crisis and felt he was fit for release, although they also acknowledge the self-harm and depression that should have triggered a review by a mental health nurse. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: For Sat. Navigation users S9 2EG E-Mail: Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: Page 5 The initial RA completed Custody Sergeant A identifies a number of triggers at the point of entering custody:- PRIVATE Can’t read or write. Mental health issues - depression Medication for mental health issues - Sertraline Self-harm- 3 weeks previous by cutting. Consuming alcohol - 2 bottles of whiskey and 12 Cans Taken any drugs- Cocaine. The PRA completed by Custody Sergeant B does not reflect any of the triggers previously identified around mental health, depression, self-harm, alcohol and cocaine use. Custody Sergeant B provides evidence that appears to acknowledge the triggers, but the completed PRA only appears to acknowledge the evidence of the demeanour of PK at the point of release. Action: The set wording of some of the questions are to be reviewed as the use of the word such as ‘appear’ is probably not correct in reference to identifying mental health issues which may not be visually apparent- these are to be reviewed as to correct wording, however the ability to change them on the CONNECT system is subject to the system developer involvement, therefore a time frame cannot be identified at this time. Action: As highlighted in response to concern 1, there is training and CPD delivered to all Custody Sergeants around the PRA, the contrast between both the RA and PRA in this case is to be adopted and utilised in continued future training to identify the ‘Lessons Learned’. This will be implemented immediately for the next available training courses. 4. A lack of understanding as to the triggers which may lead to contact with LND not just during a person's time whilst held in custody but at the point of release. Custody Sergeant B provides evidence that identifies that the references to depression and self-harm on the assessments should have triggered a review by a mental health professional, this identifies that they do know the triggers but knowing this they still did not request such a professional. Custody Sergeant A has identified that they are aware of the triggers but felt that a further assessment should be completed when not intoxicated. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: For Sat. Navigation users S9 2EG E-Mail: Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: Page 6 Action: PRIVATE As highlighted in response to concern 1, there is to be further clarification circulated to all Custody Sergeants and staff around the triggers and priorities for involving Liaison and Diversion, a flowchart will be provided by Liaison and Diversion and placed at each booking in desk for every Custody Sergeant to visually refer to when completing RA and PRA at all three suites. This is to be in place and completed by the 31st May 2024 5. It appears that there is a training need for those working within the custody suite to understand how the system works with LND and the importance of adequately addressing those who are potentially vulnerable with regard to their mental health at the point of discharge. I believe this is already identified in the concerns at points 3, 4 and 5 and the specific actions already identified plus an additional action in respect of both Custody Sergeants A and B involved in the detention of PK. Action: There is to be further clarification circulated to all Custody Sergeants and staff around the triggers and priorities for involving Liaison and Diversion, a flowchart will be provided by Liaison and Diversion and placed at each booking in desk for every Custody Sergeant to visually refer to when completing PRA at all three suites. This is to be in place and completed by the 31st May 2024 Action: There will be further guidance circulated to all Custody Sergeants around entering the “L&D” flag on the CONNECT system. This is to be completed by the 31st May 2024 given the custody shift system. Action: There has already been initial reports provided by both Custody Sergeants A and B. Further one to one discussions will be held individually with CPAG Custody Inspector to highlight the ‘Lessons Learned’ from this investigation. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: For Sat. Navigation users S9 2EG E-Mail: Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: Page 7 I hope that this provides you with assurance that the Matters of Concern that were identified are being fully addressed by South Yorkshire Police. PRIVATE Yours sincerely Chief Constable of South Yorkshire Police Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: 0114 252 3588 For Sat. Navigation users S9 2EG Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: 01482 578 266 E-Mail: LegalEnquiries@southyorks.pnn.police.uk Page 8
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