Source · Prevention of Future Deaths

Ian Deavall

Ref: 2024-0485 Date: 9 Sep 2024 Coroner: Bronia Hartley Area: Greater Manchester West Responses identified: 1 / 2 View PDF

A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other prisoners, potentially delaying critical medical responses.

Date 9 Sep 2024

56-day deadline 4 Nov 2024 est.

Responses identified 1 of 2

State Custody related deaths

Coroner's concerns

AI summary

A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other prisoners, potentially delaying critical medical responses.

View full coroner's concerns

as follow:

(1) The response to a medical emergency will generally be time critical.

(2) The risk that non-VP prisoners will victimise VP prisoners is a recognised one.

(3) That prison staff became aware of the medical emergency in the Deceased’s case was more by accident than design (depending as it did on the caprice of Prisoner A).

There remains a risk that future deaths could occur as it remains the case that emergency cell bells at HMP Forest Bank can be deactivated readily and altogether by other prisoners and no action to implement fail-safe measures is currently proposed.

Responses

1 respondent

HM Prison and Probation Service Central Government

18 Nov 2024 PDF

Action Taken

HMP Forest Bank has split the induction across two wings, housing vulnerable prisoners and non-vulnerable prisoners separately, eliminating the risk of cell call bells being cancelled by other prisoners. Plans for future investment with regards to the cell call system will be determined by the competitions process and award of future contracts. (AI summary)

View full response

Dear Ms Hartley

Thank you for your Regulation 28 report of 9 September 2024, addressed to the Ministry of Justice, following the inquest into the death of Ian Deavall on 24 January 2023 at HMP Forest Bank. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.

I know that you will share a copy of this response with Mr Deavall’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 concerns that the emergency cell bells at HMP Forest Bank can be deactivated by other prisoners and that this presents a risk to vulnerable prisoners (VPs) when they are co-located with non-VPs on the induction wing.

The technical standard for cell call systems provides details about the cell call unit, the corridor reset unit and the wing office/custody control room display unit. You have raised concerns relating to the corridor reset unit. For new accommodation and new site-wide cell call systems in prisons, the preferred option of reset is by a proximity token mounted to a key fob that can be carried by staff. However, older existing systems have manual push buttons for reset.

HMP Forest Bank has a legacy cell call system that was installed at the time of construction and wings A-F have no wing office/custody control room display unit to identify the calling cells and the status of these calls. These units are in place on wings G and H and allow staff to identify cells that have had their call bells on even if they are turned off at the door. Plans for future investment with regards to the cell call system will be determined by the competitions process and award of future contracts.

HMP Forest Bank has advised that the induction is now split across two wings, which allows VPs and non-VPs to be housed separately, which means that the risks to VPs associated with co-location, including the cancelling of cell call bells by non-VPs, are no longer present.

More generally HMPPS is committed to protecting vulnerable prisoners from abuse and neglect and PSI16/2015 Adult Safeguarding in Prison describes the range of policies that are in place to achieve this.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.

Report sections

Investigation and inquest

On 26 January 2023 I commenced an investigation into the death of Ian William Deavall, age 65. The investigation concluded at the end of the inquest on 9 September 2024.

The conclusion of the inquest was:

Ian William Deavall died as a consequence of a naturally occurring cardiac arrest. There was an admitted failure to arrange for Mr Deavall to be sent to hospital for assessment between 20 and 24 January 2023, however this did not cause or contribute to death on the balance of probabilities.

The medical cause of death was:

1. Ischaemic heart disease.

Circumstances of the death

The Deceased was remanded in custody to HMP Forest Bank on 7 January 2023. He had a known history of ischaemic heart disease and hypotension and was prescribed various medications for the same. The Deceased was housed on the induction wing throughout his time at the prison and shared a cell. Both the Deceased and his cell mate were believed to be at risk from other prisoners and were classed as vulnerable prisoners (‘VPs’) accordingly.

The inquest heard evidence that both VPs and non-VPs are housed on the induction wing and that the recognised risk to VP prisoners when co-located with non-VP prisoners is managed by operating two separate regimes to avoid the two demographics coming into contact with one another.

On 24 January 2023 the Deceased and his cell mate were locked in their cell when the Deceased suffered a cardiac arrest. His cell mate pressed the emergency cell bell whereupon a non-VP prisoner (‘Prisoner A’), who was unlocked and conversing with two other prisoners on the landing adjacent to the Deceased’s cell, deactivated the cell bell on the panel outside the cell before resuming his conversation with the other prisoners. After approximately 1 minute Prisoner A walked down to the wing office and alerted officers inside, following which a medical emergency response was initiated.

The inquest heard evidence that when an emergency cell bell in the induction wing at HMP Forest Bank is deactivated on the panel outside the cell (i) this cancels the alert in the wing office; (ii) the only means by which staff can ascertain in which exact cell the emergency cell bell has been activated (the light on the panel outside the cell) goes off.

Copies sent to

Co Secure Health Services Ltd

Similar PFD reports

Shared signals

Report details

Reference: 2024-0485
Date of report: 9 September 2024
Coroner: Bronia Hartley
Coroner area: Greater Manchester West

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Nov 2024 (estimated).

Sent to

HM Prison and Probation Service

Ministry of Justice

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.