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recurance

Arthur Morley

4 Apr 2017 · Coroner Crispin Butler · Buckinghamshire

The coroner's concerns

  1. 1. open pipes in sanitation rooms accessible at night

    “The death occurred in December 2015. Since then there does not appear to have been a specific audit of possible ligature points on the wings, particularly pipework in the sanitation rooms, which remain accessible at night to prisoners but are out of view of wing staff. There are no current proposals to undertake works to reduce accessibility of ligature points such as open pipes.”
  2. 2. unlocked shower facilities at night

    “The Local Operating Procedure LOP49 requires locking off of shower facilities at night such that prisoners would only have access to toilet facilities. Locking shower facilities could reduce access to possible ligature points. There is some work being undertaken to address the issues that many sanitation room doors cannot be locked but there appears to be no specific timescale or urgency to the implementation of this proposal.”
  3. 3. lack of cold debrief and Serious Incident Report

    “Whilst there was a hot debrief conducted very shortly after Mr [name redacted] death, there was no cold debrief and no Serious Incident Report. There is due to be a post-inquest debrief but as issues have emerged during the PPO investigation and the Coroner's”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error