Nathan Shepherd
22 Jan 2025 · Coroner Alison Mutch · Manchester South
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. residents barricading themselves into rooms
“The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at Approved Premises”
2. lack of coordination with Police Forces
“A copy of the draft policy was available to the inquest but it was unclear what if any discussion there had been with Police Forces and how it would link in with Police policies such as the GMP Right Care Policy”
3. movable furniture enabling barricade
“The evidence before the inquest was that Mr [name redacted] was able to barricade himself with relative ease due to the mobility of the furniture in his room”
4. ligature point in premises
“The [REDACTED] was a ligature point”
5. absence of CPR training policy for agency staff
“Agency staff were used under a national contract. The evidence before the inquest was that at the time of Mr [name redacted] death there was no policy for ensuring they could deliver CPR / First Aid”
6. lack of understanding of information flow
“Evidence from Probation and Prison staff showed a lack of understanding of how the prison system could update the probation system and where that information could be found”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited. Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be shared.”
This report
“Evidence from Probation and Prison staff showed a lack of understanding of how the prison system could update the probation system and where that information could be found.”
Responses
2025-0038-Response-from-HMPPS.pdf ↗· Ministry of Justice
Stated action · 1st August 2025 and end of September 2025
“The Barricade Guidance referred to in evidence given at the Inquest hearing has now been finalised and is going through the final stages of sign off prior to issue to all approved premises staff on 1st August 2025. This guidance will form part of the Safe Working Practice document and staff will be required to acknowledge receipt and their understanding by the end of September 2025. This will be overseen by all Approved Premises Managers.”