Sean Davies
8 Aug 2024 · Coroner Patricia Harding · Mid Kent and Medway
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. IPP sentence risk factor for suicide and self-harm
“1) There are currently 55 prisoners at HMP Swaleside subject to IPP sentences. It has been recognised by the Prison and Probation Ombudsman that an IPP sentence should be regarded as a potential risk factor for sucide and self harm (learning lessons bulletin September 2023). In the clinical review following the death of Mr [name redacted] a recommendation was made that the Governor and Head of Healthcare ensure that a risk formulation was completed for all prisoners subject to IPP sentences, that it was”
2. Missing welfare checks
“It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies”
3. Inadequate fire regulation training and non-compliance with handovers
“One operational support group officer had not received training in relation to fire regulations or handovers, another did not act in accordance with the training”
Linked reports
Closely relatedConfidence 0.92 · high
Earlier report
“Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response from the prisoner upon unlocking a cell or were aware but did not act in accordance with the order especially where they assumed the prisoner was asleep”
This report
“It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies”
Closely relatedConfidence 0.90 · high
Earlier report
“That measures put in place following Mr. [name redacted] death to ensure welfare checks are conducted are not overlooked”
This report
“(2) It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies”
Responses
No published response was found on judiciary.uk.