Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, written 14 Dec 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Dec 2015 |
|---|---|
| Deceased | Daniel Byrne |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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Mr Thomas Osborne HM Senior Coroner for Milton Keynes REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Claire Murdoch, Chief Executive, Central and Northwest London NHS Trust CORONER | am Mr Thomas Osborne, HM Senior Coroner for Milton Keynes CORONER’S LEGAL POWERS | 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 INVESTIGATION and INQUEST On 2™ March 2015 | commenced an investigation into the death of Daniel Brendan Byrne, aged 28. The investigation concluded at the end of the inquest on 14" December 2015. The conclusion of the inquest was that ‘There was a failure by both the healthcare staff and prison officers to carry out an adequate risk assessment for self harm and suicide. There was a failure to refer Daniel Byrne for an urgent mental health assessment. There was a failure to carry out the first ACCT case review adequately. Daniel Byrne deliberately chose to suspend himself by a ligature but we are not satisfied that he intended that the outcome be fatal.’ | CIRCUMSTANCES OF THE DEATH The circumstances of his death are that he died on 27th February 2015 at Milton Keynes Hospital following resuscitation after a suicide attempt in his cell between 12.30-1.00pm on 26th February 2015 at Woodhill Prison. He made a ligature from sheets in his cell and hung himself by the neck from the external grill outside the window of his cell. His cause of death was given after post mortem examination as 1a) Severe Hypoxic/Ischaemic Brain Injury Following Hanging (With Initial Resuscitation). 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. — In the Independent Investigation Report from the Prison and Probation Ombudsman, the author refers to previous deaths at Woodhill and says: “Mr Byrne’s was the seventh self inflicted death at Woodhill since 2013 and there have been two since. We are concerned that many of the same issues have been repeated in a number of their investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.” My concern is that during the evidence from the Nursing Staff, it appears that they did not participate fully in the health screen at reception or at the first review of Mr Byrne’s ACCT. There needs to be a review of the healthcare staff's role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare. Consideration should also be given to the introduction of a formal risk assessment tool. HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ Tel 01908 254326 | Fax 01908 253636 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 8" February 2016. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons e Family of Mr Daniel Byrne e The Prison and Probation Ombudsman e The Treasury Solicitors | 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 repres ‘the coroner, at the time of your response, about the release or the publicati /l \e Chief Coroner. Signature for Milton Keynes HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ Tel 01908 254326 | Fax 01908 253636
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