Source · Prevention of Future Deaths

Idris Habib

Ref: 2022-0020 Date: 24 Jan 2022 Coroner: Patricia Harding Area: Mid Kent and Medway Responses identified: 1 / 1 View PDF

Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' actions.

Date 24 Jan 2022
56-day deadline 23 Mar 2022
Responses identified 1 of 1
Mental Health related deaths State Custody related deaths

Coroner's concerns

AI summary
Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' actions.
View full coroner's concerns
(1) Medication from the previous occupant of cell B1-18 was found in the cell following the death of Mr Habib (2) There was a disconnect between HMP Swaleside's local policy and the Prison Officer

Responses

1 respondent
HM Prison and Probation Service Central Government
30 Mar 2022 PDF
Action Taken

HMP Swaleside issued a notice in November 2021 reminding staff of cell clearance procedures and reinforced the process during staff briefings. Since the inquest, the prison has introduced a welfare check at approximately 8am requiring staff to gain a verbal response from the occupant, with completion of the check recorded in the wing assurance book, with staff re-issued a notice to remind them to satisfy themselves of the prisoner's wellbeing. (AI summary)

View full response
Dear Ms Harding,

Thank you for your Regulation 28 report of 24 January 2022 following the inquest into the death of Idris Habib on 20 November 2018. I am responding as the Director General of Prisons.

I know that you will share a copy of this response with Mr Habib’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 raised three concerns regarding cell clearance procedures, roll checks and welfare checks, which I will address in my response.

In November 2021, HMP Swaleside issued a notice reminding staff of the process to be followed when undertaking cell clearance checks to ensure that any items belonging to previous occupants are removed before the next prisoner is moved to that cell. Any medication found should be placed into a security bag and an intelligence report must be submitted. The notice also reminded staff that a pre-occupancy check should be undertaken and documented before the cell is allocated to another prisoner. This process was also reinforced during staff briefings.

In respect of staff checks on prisoners, it may be helpful for me to first clarify the types of checks that staff are required to conduct on prisoners.

Roll checks are undertaken as a fundamental security check to ensure that all prisoners are present in each area of the prison at particular times of the day. While the primary purpose of these checks is to ensure all prisoners are accounted for, staff are required to take any necessary action if there are any immediate concerns for a prisoner’s welfare.

Welfare checks are undertaken by staff during or shortly after unlock so they can assure themselves of the wellbeing of prisoners. This can include verbal or physical acknowledgements, movement in a cell or in bed, or any other indication that a person is

alive and there are no obvious issues of concern. Further, as part of the Assessment, Care in Custody and Teamwork (ACCT) process, welfare observations are carried out on those who are considered to be at risk of self-harm or suicide to ensure these individuals are safe. Observations will be carried out at irregular intervals and in the least obtrusive manner, particularly at night given the importance of sleep for wellbeing.

All prisons are required to have a local policy which sets out what staff are required to do during checks, in order to ensure the above requirements are met. Local instructions and policies will supersede training individuals may have had as they set out the expectations of that individual establishment.

I fully recognise the implications of any checks not being carried out as they should be. HMPPS would expect staff to take swift action if they have any concerns about an individual’s welfare no matter what type of check is being conducted.

Since Mr Habib’s inquest, HMP Swaleside has introduced a welfare check that staff conduct at approximately 8am. Staff must open the cell door and ensure they gain a verbal response from the occupant so they can assure themselves of the prisoner’s wellbeing. The completion of the check must be recorded in the wing assurance book. Additionally, the prison has re-issued a notice to remind staff that they must satisfy themselves that the prisoner is alive and gain a verbal response when completing welfare checks. This has also been highlighted during full staff briefings that take place three times a week.

I hope the measures outlined above provide you with reassurance that learning and appropriate action has been taken from the circumstances of Mr Habib’s death.

Report sections

Investigation and inquest
On 28 November 2018 I commenced an investigation into the death of Idris HABIB. The investigation concluded at the end of the inquest . The conclusion of the inquest was Narrative: Idris Habib took his own life when he hung himself in his cell, B1 - 18, but his intention in doing so is unclear. On 16th November 2018 Idris Habib set a fire in his cell and stated that he wanted to kill himself. There was a failure to open an ACCT following this, however it can not be concluded that these factors contributed to his death. 1a Hanging 1b

1c

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Report details

Reference
2022-0020
Date of report
24 January 2022
Coroner
Patricia Harding
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: 23 Mar 2022.

Sent to

HMP Swaleside

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