Source · Prevention of Future Deaths

Jonathon Lawlor

Ref: 2024-0667 Date: 25 Nov 2024 Coroner: Catherine Wood Area: Mid Kent and Medway Responses identified: 1 / 1 View PDF

Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.

Date 25 Nov 2024
56-day deadline 17 Jan 2025
Responses identified 1 of 1
Alcohol, drug and medication related deaths State Custody related deaths

Coroner's concerns

AI summary
Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.
View full coroner's concerns
[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Mr. Lawlor only had two keywork sessions during the 4 months he was on remand at HMP Elmley. The reasons given were that staff shortages meant that key working sessions were not able to be offered. Offender Management in Custody(OMiC) guidance suggests that good practice entails an officer having a caseload of five or six prisoners who they will meet once a week for a key working meeting. The Prison and Probation Ombudsman who also investigated the death were aware that due to staff shortages the priority at the time of Mr. Lawlor's death were to have monthly sessions and that the prison was to increase provision as their staffing picture improved. On that basis they made no recommendations. Whilst the number of keywork sessions Mr. Lawlor had did not play a part in his death it may be the case that key-working sessions for prisoners can assist with reducing risks for others in custody. Evidence heard at the inquest revealed that the target had been unachievable due to staffing pressures and as a large number of prisoners (approximately 70%) are on remand and stay between zero and six months the turnover is high and the prison is busy. There was also some scepticism as to whether it was the right model.

Responses

1 respondent
HM Prison and Probation Service Central Government
16 Jan 2025 PDF
Action Planned

HMP Elmley has been compiling a Key Work Delivery Strategy to address and improve the issue of key work, with the goal of ensuring that all prisoners are allocated a key worker and that specific cohorts of prisoners at risk of harm or self-harm are identified and supported by trained staff members. For 2025/6 the minimum expectation for key work delivery will rise to two key work sessions every four weeks as a minimum. (AI summary)

View full response
Dear Ms Wood, Thank you for your Regulation 28 report of 25 November 2024 following the inquest into the death of Jonathon Paul Lawlor at HMP Elmley on 19 October 2023. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the Director General of Operations. I know that you will share a copy of this response with Mr Lawlor’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You have expressed a concern regarding the delivery of key worker sessions provided at HMP Elmley. Thank you for bringing your concerns to my attention. In January 2024 I wrote to all Area Executive Directors, Prison Group Directors and Governors setting out the HMPPS operational priorities for 2024/5 and the related core expectations. One of these priorities was to increase the quantity and quality of regimes, including key work, and to support this a new regime and business planning process has been introduced. The core expectations for key work delivery are that prisons must utilise all their allocated resource for this task and that it must be profiled. Every prisoner must receive one key work session every four weeks as a minimum, and any remaining resources must be targeted at an enhanced offer for individual prisoners based on an assessment of risk, need and cohort prioritisation. Local action is also underway. The Custodial Manager who oversees keywork at HMP Elmley has been compiling a Key Work Delivery Strategy to take forward as we move into
2025. This strategy details HMP Elmley’s plan to address and improve the issue of key work within the establishment.

The goal is to ensure that all prisoners are allocated a dedicated key worker at the point they are moved from the induction unit to a permanent houseblock. These key workers will be staff from that particular houseblock to enable the building of better relationships between the staff member and prisoner and enable the prisoner to feel they have a trusted point of contact on the unit, giving them confidence to speak to their key worker about any sensitive subjects that may arise. For continuity, if after being allocated a key worker a prisoner is moved from one houseblock to another the key worker allocation will not change HMP Elmley recognise that specific cohorts of prisoners are either more at risk of harm or self-harm or are more vulnerable than others to incidences such as bullying. To manage this risk certain staff members have been identified and will work specifically with these cohorts, the aim being to have these staff upskilled in the areas that they are allocated to so they can help these individuals and lower the: violence, self-harm, non-compliance and bullying rates within the establishment. We currently have a member of staff from each houseblock dedicated to young offenders with the aim of increasing these dedicated cohorts over the coming months. Additional key work is also offered to those that reside on our neurodiverse landing and key work is offered each weekend within the in-patient department (IPD) and the Care and Separation Unit (CSU). Key work is one of the core priorities for HMPPS in 2025/26. The expectation will be that key work delivery will increase in this cycle of regime planning, aligned to each establishment Regime Management Plan. Additional elements have been added to the Regime Planning Template to enable establishments in their key work delivery. For 2025/6 the minimum expectation for key work delivery will rise to two key work sessions every four weeks as a minimum. I hope the measures outlined above provide you with reassurance that learning and appropriate action has been taken from the circumstances of Mr Lawlor’s death.

Report sections

Investigation and inquest
On 27 October 2023 I commenced an investigation into the death of Jonathon Paul LAWLOR. The investigation concluded at the end of the inquest . The conclusion of the inquest was The deceased died as a result of an accident. 1a Acute Multi-Organ Failure With Pulmonary Congestion and Oedema 1b Cocaine Toxicity 1c 1d

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Report details

Reference
2024-0667
Date of report
25 November 2024
Coroner
Catherine Wood
Coroner area
Mid Kent and Medway

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Jan 2025.

Sent to

HM Prison and Probation Service

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