Jason Williams
2 Feb 2023 · Coroner Rachael Griffin · Dorset
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of specific and dedicated national guidance to define and care for vulnerable prisoners
“There was a differing opinion between professionals including those from the healthcare, Integrated Substance Misuse Service (ISMS) and prison staff as to whether [the deceased] was vulnerable. Evidence was given that there is no national guidance either from HMPPS or the NHS on how to care for vulnerable prisoners in custody. It was confirmed that there is reference in certain documents such as PSI 64/2011 to vulnerability but no specific dedicated guidance on vulnerability. There is no definition of”
2. ineffective keyworker programme
“The current keyworker programme is not working as planned at HMP Guys Marsh and there was reference to this also being reflected nationally. I would request that consideration is given to a review being undertaken of the keyworker programme within the whole prison estate, and also specifically at HMP Guys Marsh.”
3. inadequate record keeping on NOMIS
“In the NOMIS case notes for [the deceased] there did not appear to be regular entries from Prison staff.”
4. missing Governor notice on psychoactive substance risks
“A Governor notice was not issued in the time leading up to [the deceased]'s death to prisoners or staff around the concerns regarding access to, and the impact of using, psychoactive substances.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“At the time of [the deceased]'s death, the use of psychoactive substances was a problem at HMP Guys Marsh as it was, and continues to be, across the prison estate.”
This report
“A Governor notice was not issued in the time leading up to [the deceased]'s death to prisoners or staff around the concerns regarding access to, and the impact of using, psychoactive substances.”