Source · Prevention of Future Deaths

Lewis Powter

Ref: 2022-0223 Date: 21 Jul 2022 Coroner: Lorna Skinner Area: Cambridgeshire and Peterborough Responses identified: 0 / 2 View PDF

There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack access to shared record systems.

Date 21 Jul 2022
56-day deadline 15 Sep 2022
Responses identified 0 of 2
Alcohol, drug and medication related deaths Mental Health related deaths

Coroner's concerns

AI summary
There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack access to shared record systems.
View full coroner's concerns
where an IPP offender with complex needs is released and is not subject to MAPPA, but is subject to multi-agency intervention co­ ordinated by the National Probation Service, there is no policy/procedure/guidance encouraging consideration to be given to the issues of whether and when to hold multi-agency meetings for the purposes of sharing information about the offender. The need for consideration to be given to holding such meetings is particularly acute where one of the organisations responsible for delivering care/treatment does not have access to the shared record system used by the other two parties.

Report sections

Investigation and inquest
On 21 May 2020 I commenced an investigation into the death of Lewis Martyn POWTER, who died on 10 May 2020 aged 36 years. The investigation concluded at the end of the inquest on 19 July 2022. Medical Cause of Death – overdose Conclusion – Drug related.
Circumstances of the death
Mr Powter was an IPP offender who had been diagnosed with emotionally unstable personality disorder and had been addicted to drugs for over 10 years. When in the community, he, in common with a number of IPP offenders, suffered from continued anxiety over the issue of potential recall. On release in November 2019, Mr Powter was put on the Offender Personality Disorder (OPD) pathway - a community based service which is part of a joint national strategy shared between probation and health service providers which have access to a shared computer log system, nDelius, for these purposes. As a result of his substance misuse issues, Mr Powter was also under the care of Change Grow Live (“CGL”), a charitable organisation, and was prescribed Subutex. As a third sector organisation, CGL did not have access to nDelius. A multi-agency meeting in respect of Mr Powter took place between the local NHS Trust, probation and CGL in January 2020. There was no further such meeting about him, despite his ongoing vulnerabilities as described above and: (a) the potential impact of lockdown upon him; and (b) the fact that he reported that he had stopped taking his prescription for subutex and was abstaining from drugs. Having abstained from drug-taking for over a month, with the result that he had a reduced tolerance level, Mr Powter died of a self-administered overdose on 10 May 2020. At that time, he was experiencing increased anxiety because, as an IPP liable to recall to prison at any time he had, on 4 May 2020, been identified to the police as the perpetrator of an assault and was informed that he would be facing court proceedings in relation to it.
Copies sent to
Cambridgeshire and Peterborough NHS Foundation Trust

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Report details

Reference
2022-0223
Date of report
21 July 2022
Coroner
Lorna Skinner
Coroner area
Cambridgeshire and Peterborough

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Sep 2022.

Sent to

Ministry of Justice
NHS England

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