Vincent Oliver
9 Oct 2014 · Coroner Tony Brown · Northumberland (North)
The coroner's concerns
1. death of inmate due to lack of response during cell unlocking
“The prison officer unlocking Mr [name redacted] cell on 4th July 2013 at approximately 5.40 p.m. for the evening meal did not check on his physical well-being by getting a response from him, before moving on to the next cell. This led to Mr [name redacted], who had died some time earlier and was affected by rigor mortis, being found by another prisoner when he entered Mr [name redacted] cell.”
2. repeated failures in cell unlocking procedures
“There has been a number of other occasions at the prison when appropriate cell unlocking procedures have not been followed and the Prisons and Probation Ombudsman has made recommendations about this previously.”
3. lack of documentation confirming compliance with roll check response requirement
“I understand that a Prison Director's Order has been issued requiring that on roll check Prison Officers must obtain a response from each prisoner to ensure their physical presence and well-being. My understanding of the procedures is that there is no current requirement for the Officer completing the roll check to record on the roll check report that he or she has complied with the requirements of the above Order.”