Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0071, written 6 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Feb 2026 |
|---|---|
| Reference | 2026-0071 |
| Deceased | Emmett Morrison |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1) The Minister of State for Prisons, Probation and Reducing Offending, Ministry of Justice, 102 Petty France, London SW1H 9AJ 1 2 CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire. 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 18 October 2024 I commenced an investigation and opened an inquest into the death of Emmett Peter MORRISON aged 40. The investigation concluded at the end of the inquest on 06 February 2026. The conclusion of the inquest was that: "Emmett Morrison died as a result of suspending himself by a ligature It is not possible to determine what his intention was at the time he did this. See Questionnaire: QUESTIONNAIRE When you provide your answers, circle where appropriate. (a) Did the admitted failure to consider and include on the ACCT Care Plan 1. support actions to try to mitigate Emmett’s risk of suicide and/or self-harm possibly cause or contribute to his death on 16 October 2024? YES 2. review have been arranged sooner than 14 October 2024? Following the ACCT review on 8 October 2024, should a further ACCT YES 3. contribute to Emmett’s death on 16 October 2024? If your answer to Question 2 above is YES, did that failure possibly cause or YES" 4 CIRCUMSTANCES OF THE DEATH On 13.10.24 Mr. Morrison, who was a serving prisoner since May 2023 at HMP Long Lartin, was found suspended by a ligature in his cell. He was resuscitated and taken to Worcestershire Royal Hospital where on 16.10.24 he died from his injuries. 5 CORONER’S CONCERNS 1 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) Continued influx of drugs into HMP Long Lartin Throughout Emmett’s time at HMP Long Lartin, and at the time of his death, the influx of illicit drugs into the prison was a major problem. HMP Long Lartin is a high security prison, a large proportion of whose inmates are serving lengthy sentences. The demand for, supply and distribution of drugs within the prison is therefore capable of causing significant disruption to its security and stability, as well as posing significant risk to the wellbeing of prisoners and staff working there. Staff at the prison are doing all they can to try to reduce the demand for these drugs, and to assist those dependent on them, but their job is being made considerably harder by the continued and steady flow of illicit substances into the prison. I have been told in evidence that HMP Long Lartin has been identified as one of the two prisons in the country with the biggest issues in this regard. I have also heard evidence that measures put in place since Emmett’s death have reduced the number of drone drops of drugs into the prison, and that funding is now in place to install grilles on windows at the prison to prevent prisoners reaching out to retrieve drugs from those drones, although that work is yet to be carried out. Those involved in the supply of drugs within the prison are often part of highly sophisticated organised crime groups, and unless proper measures are put in place at the prison, its regime and the welfare of its staff and prisoners will continue to be placed at risk as the influx of drugs continues. Class A drugs, which continue to be used within the prison, present a clear and obvious risk to the lives of those who use them. Novel Psychoactive Substances, like Spice, the make-up of which can change from batch to batch and makes detection problematic, and whose effects can be both unpredictable and life-threatening, as was apparent in EM’s case, also remain prevalent throughout the prison. 2) Failures in ACCT process Emmett was a prisoner with a considerable history of substance misuse and self-harm while in custody. Of the eight ACCT reviews which were conducted after Emmett's ACCT document was re-opened on 10.9.24, not one resulted in any support actions being entered onto the ACCT care plan. The ACCT care plan is a key part of the ACCT process, which requires those taking part in ACCT case reviews to set in train actions designed to reduce the prisoner’s risk of suicide or self-harm. As the guidance then in force made plain, it is a mandatory part of the ACCT process. The reasons given by staff who took part in these ACCT reviews for not having done this included: (i) being sure that they had talked about it, but had not noted anything down; (ii) thinking that, if EM didn’t attend an ACCT review, they couldn’t put any actions in place because that could only be done with his agreement; and 2 (iii) they were so weighed down by the number of ACCT reviews which they had to carry out and the rest of their workload, that they simply had no time to complete this part of the review. Most worryingly, two of those witnesses who cited a heavy workload and pressures of work for Care Plans not being completed, made clear that not only this was commonplace at the time of these events but also that it is still an issue. Despite hearing evidence that measures have been put in place to train officers conducting ACCT reviews, and to conduct Quality Assurance checks on open ACCT documents, I was left with the clear impression that ACCT Care Plans are still being overlooked. I also note that as long ago as 2021 this court heard an inquest into the death of a prisoner at the same prison in 2018, following which I wrote a Prevention of Future Deaths report to the then Governing Governor of the prison, indicating my concern that ACCT Case Reviews for that prisoner had, on several occasions, failed to review or add actions to the ACCT Care Plan. It is therefore a concern that, 6 years on from that prisoner's death, the same issue arose in Emmett's case. As long as that remains the case, the lives of those vulnerable prisoners whom the ACCT process is designed to protect will continue to be put at risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the nominated individual responsible for the care home, 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 3 April 2026. 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: ( Emmett’s mother ) ( solicitor, Government Legal Department ) ( solicitor, Hill Dickinson LLP, representing Practice Plus Group ) Partnership NHS Foundation Trust ) ( solicitor, Browne Jacobson LLP, representing Midlands I am also under a duty to send the Chief Coroner a copy of your response and all interested persons who in my opinion should receive it. 3 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 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 6 February 2026 David REID HM Senior Coroner for Worcestershire 4
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 Senior Coroner David Reid Worcestershire Coroners’ Court The Civic Offices Worcester Worcestershire HR2 1LH Email: 31 March 2026 Dear Mr Reid REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Thank you for your Regulation 28 reports of 6 February 2026 following the inquest into the death of Emmett Morrison at HMP Long Lartin, addressed to the Minister of State for Prisons, Probation and Reducing Reoffending, and to the Governing Governor of HMP Long Lartin. I am responding to the issues raised in both reports on behalf of HMPPS as Director General of Operations. I know that you will share a copy of this response with Mr Morrisons’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. Following evidence heard at the inquest, you have raised concerns regarding the ingress of illicit drugs and the adequacy of the ACCT process in managing risk for vulnerable prisoners at HMP Long Lartin. As you will be aware there are multiple routes through which drugs can enter prisons, influenced by factors such as security measures, geographical location and the prisoner cohort. Common attempted conveyance routes include prisoners arriving into custody, prison visits, correspondence, items thrown over perimeter walls and the use of drones. Our approach to tackling conveyance is therefore multi-faceted. In the 2025/26 financial year, we are investing over £40 million in physical security measures across 34 prisons, including £10 million on anti-drone measures such as window replacements, external window grilles and specialist netting across 15 priority prisons, both of which initiatives HMP Long Lartin will benefit from. Prisoners caught smuggling contraband may face additional time in custody, loss of privileges and other sanctions depending on the nature and quantity of the items. The most serious cases, including smuggling drugs with intent to supply, are referred to the police, and the Crime in Prisons Taskforce has been established to work closely with police and the CPS to improve the quality of referrals and prosecutions for crimes committed in prisons. We work closely with health partners to identify prisoners with a drug use need, refer them into treatment, support recovery and reduce demand. We have funded Incentivised Substance Free Living Units in 88 prisons, including at HMP Long Lartin, where prisoners sign a behaviour compact, agree to regular drug testing and can access enhanced opportunities compared to a standard wing. There are 54 Drug Strategy Leads in key prisons, including HMP Long Lartin, whose role is to support effective implementation of local drug strategies and ensure a whole-system approach to tackling drugs, complemented by Drug and Alcohol Leads at Prison Group level who support prisons across the estate. Naloxone, an essential life-saving medication capable of reversing opiate overdose, is now available in 99% of prisons. Naloxone training has been embedded into the foundation training for all new prison officers, and more than 10,000 staff have been trained to date. We have also invested in multiple physical countermeasures and initiatives to address conveyance. X-ray body scanners are in place across all adult male closed prisons and are used where prisoners are suspected of internally concealing illicit items. HMP Long Lartin is one of 54 priority establishments where Enhanced Gate Security operates to search staff and visitors using archway metal detectors, handheld detection wands and x-ray baggage scanners. Drug trace detection equipment is available in all public-sector prisons to test suspect items and incoming mail for drug-laced paper or fabric, and dedicated search teams are also available to be deployed, equipped with specialist tools to deter conveyance and disrupt drug dealing within the estate. Alongside these measures, we are working hard to deter, detect and disrupt the use of illegal drones. Our multi-faceted approach includes physical security enhancements, technological development, intelligence exploitation, strengthened legislation and close collaboration with international partners. Targeted countermeasures such as window government and improvements, specialist netting and grilles are deployed to prevent drones successfully delivering contraband. We work closely with law enforcement, with the Director General of the National Crime Agency (NCA) directing police chiefs to work jointly with HMPPS to tackle drone threats. All closed prisons and young offender institutions have 400-metre Restricted Fly Zones, making any unauthorised drone incursion a criminal offence and supporting staff and police in disrupting drone activity. Comprehensive guidance has been developed, staff are being upskilled, and vulnerability assessments are carried out across the estate to understand risk and implement mitigation plans. The Ministry of Justice takes the threat of serious and organised crime extremely seriously, recognising that drone conveyance is intrinsically linked to organised crime groups. HMPPS has a dedicated national Serious Organised Crime operational function which works collaboratively with law enforcement and partners to identify and disrupt organised criminal activity within both the prison estate and the community which has recently been expanded, increasing specialist support for managing organised crime risks and strengthening law-enforcement partnerships. The national team provides targeted support to the most at-risk prisons, ensuring that local security strategies are aligned with national intelligence and operational priorities, while Area Intelligence Units play a vital role in gathering and analysing intelligence on serious and organised crime within prisons. Regarding your concern about the ACCT process, the Prison Safety Policy Framework which was implemented on 1 January 2025, and superseded PSI 64/2011, requires that an ACCT case review team must set and review support actions to mitigate the risks identified. The ACCT Case Co-ordinator is expected to record the areas of risk discussed at a case review, update the Care Plan, including the support actions and note the rationale for the decisions of the case review team. The policy requires that support actions are identified, even if a prisoner does not engage with an ACCT case review. It also requires that, if a prisoner is unwilling to participate in a case review, staff must record the reason they did not attend and update the prisoner on the outcome of the review, including any agreed actions. The prisoner must sign and agree the support actions form, but if they decline to do so, this must be documented. Safety training covers defensible decision-making and evidence-based care planning. Training packages specifically for ACCT Case Coordinators upskill staff in the development of individualised care plans. Since the death of Emmett Morrison, locally, the Quality Assurance processes have been updated, with four Quality Assurance checks introduced in line with the Prison Safety Policy Framework.. These new checks are now completed at HMP Long Lartin as follows: Check A – Completed by Safer Custody: Assurance check of initial processes following the opening of an ACCT, including the ACCT Plan, front cover, key information, risks, triggers, protective factors, contribution forms, IAP and Assessment. Check B – Completed by Safer Custody: Assurance check of risks, triggers, protective factors, sources of support, support actions, the first case review, ongoing record and NOMIS. Check C – Weekly assurance check: Assurance check on subsequent case reviews, including risks, triggers, protective factors, ensuring support actions are added to the Care Plan, and checking the ongoing record and NOMIS. The date of the last Check C will be added alongside ACCT information in the daily operational morning meeting briefing. Any ACCTs managed by a Custodial Manager (complex cases) will have weekly Check C’s completed by Safer Custody, and Duty Governors now complete a Check C during their weekend duty. Check D – Completed by Safer Custody: Assurance check of the closure of the ACCT document and the post-closure process. Findings from these assurance checks are shared with the case co-ordinator, line manager and Safer Custody Managers for further action where required. All Quality Assurance checks are monitored and uploaded onto a Quality Assurance analysis tool, with findings fed back at the monthly Safety Meeting for follow-up action where appropriate. Additionally, since the death, the prison has implemented a new single case management allocation system. All open ACCTs are now assigned to a Supervising Officer or, for complex cases, a Custodial Manager. Only staff who have completed the required two-day ACCT case review team course can be allocated ACCTs or conduct reviews. As of 19 February 2026, the prison has 20 open ACCTs, each managed by an individual Case Co-ordinator. Reviews are scheduled for times when the allocated Case Co-ordinator is on duty, with others stepping in only in exceptional circumstances. A buddy system has also been introduced so a nominated colleague can cover tasks during absences, ensuring continuity of care and preventing over-allocation. Witnesses who believed they could not add Care Plan actions because the prisoner had not attended the review are being booked onto refresher training, and the prison has also prioritised Suicide and Self-Harm Awareness Training (SASH) on monthly lockdown training days. In addition, National Safety Team colleagues provided one-to-one ACCT coaching to 21 Case Co-ordinators, supported by Safety Leads, in January 2026. On behalf of the Governor, I would also like to offer you the opportunity to visit HMP Long Lartin, so that you may see first-hand the positive work the prison is committed to delivering and view the improvements they are making to processes and procedures. Thank you for bringing your concerns to my attention. I trust that this response provides assurance that action has been taken to address them. Yours sincerely, Director General of Operations
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