Kane Boyce
17 Jan 2024 · Coroner Laurinda Bower · Nottingham and Nottinghamshire
The coroner's concerns
1. ignoring cell bells
“It is important to note that at the time of [the deceased]'s death, the prison was managed by Serco Ltd under a contract awarded by HMPPS. Since [the deceased]'s death, the contract for managing the prison has been awarded to Sodexo. Sodexo were invited to submit learning evidence to the court, if such existed, but instead said they would respond to any prevention of future death report I felt was necessary.”
2. lack of under the influence log
“Failure to follow the local Under the Influence Policy”
3. misunderstanding of key date triggers
“A number of prison officers believed [the deceased]'s birthday was incapable of amounting to a "key date or anniversary" for the purposes of PSI 64/2011”
4. misapplication of ACCT threshold
“A number of prison officers gave evidence that an ACCT was not necessary because [the deceased] had not said to anyone that he was going to harm himself”
5. failure to learn from prior deaths
“Many of the staff giving evidence explained that they had not read the PPO report, nor were they aware of the issues identified by the PPO prior to giving evidence at the inquest”
6. inaccurate ELR conclusions
“Poor Quality Early Learning Review process, November 2021”
Responses
2024-0034-Response-from-HMPPS.pdf ↗· His Majesty's Prison and Probation Service
Stated action
“We are currently working on a new policy framework on the follow-up to deaths in custody (replacing PSI 64/2011) and intend to use that to mandate the early learning review process, and to make clear that it is the responsibility of the Prison Group Director to satisfy themselves of the quality of the ELR before signing the report off. Alongside the new policy framework, we will issue a revised standard template and a refreshed guidance document.”
2024-0034-Response-from-Sodexo.pdf ↗· Sodexo
Stated action
“Sodexo agrees that wilfully ignoring cell bells is a wholly dangerous practice and one that is not permitted by Sodexo in any circumstances. Sodexo requires all cell bells at HMP Lowdham Grange to be answered within 5 minutes.”
Stated action
“The Governor's Order, already attached as Appendix 1, makes clear that power should not be isolated to a cell unless approved by the Duty Director (which would be either Director or Deputy Director within Sodexo) on the grounds of health and safety.”
Stated action
“Policy Sodexo have concerns about the practices of the staff that transferred to Sodexo with HMP Lowdham Grange. These include failures of staff to conduct observations and follow the Under the Influence Policy. This is part of an ongoing culture change that we are trying to address but one that takes time and has to date involved changes to Senior Managers and Officers at the prison. The Governor's Order, Appendix 1, makes it clear that staff are to open an under the influence log and inform”
Stated action
“Sodexo follow the national Prison Service Instruction 64/2011 which provides the framework underpinning any local policy. Sodexo deliver to staff the national training package issued by HMPPS for ACCT, version 6 and ACCT Assessor. To enable this Sodexo facilitators complete the national ACCT Train the Trainer course delivered by HMPPS facilitators. Relevant Sodexo staff also receive the national training package delivered directly by HMPPS facilitators on ACCT Case Coordinators.”
Stated action
“The MOJ have confirmed that all managers, including the Senior Leadership Team, are to undergo the national ACCT training as a matter of urgency, this will include ACCT Assessor training and case manager training. When the operational management of the prison returns to Sodexo all staff will undergo ACCT refresher training, if not done before.”
Stated action · within 7 days
“Following a death in custody at a Sodexo prison (whilst under Sodexo operational management) an Early Learning Review is required - this should be completed within 7 days. The Early Learning Review notes areas of good practice and recommendations, the Director is expected to ensure that any recommendations are complied with - alongside any recommendations made by the PPO.”