Tyrone Givans
23 Jan 2019 · Coroner ME Hassell · London Inner (North)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. spice smoking in prison cell
“Mr [name redacted]' former cell mate gave evidence that he had seen Mr [name redacted] smoking Spice in their cell on two or three occasions, saying that its use is common within the prison. The jury heard that Spice often makes the user scared and paranoid, and can provoke immediate, extreme and uncharacteristic behaviour.”
2. duplicate NOMIS records causing missing healthcare records
“A past spelling error meant that there were two sets of NOMIS prison records for Mr [name redacted]. This meant that there were then two sets of SystmOne healthcare records.”
3. lack of deaf awareness and delayed hearing aid provision
“Some members of discipline and healthcare staff did not appreciate that Mr [name redacted] was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer. There was a delay in seeking Mr [name redacted]' hearing aids and it took two weeks for one to be brought in by a family member.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records”
This report
“A past spelling error meant that there were two sets of NOMIS prison records for Mr [name redacted]. This meant that there were then two sets of SystmOne healthcare records.”
Responses
2019-0028-Response-by-Care-UK.pdf ↗· Care UK
2019-0028-Response-by-HM-Prison-and-Probation-Service.pdf ↗· His Majesty's Prison and Probation Service