Source · Prevention of Future Deaths

Mark Castley

Ref: 2021-0427 Date: 22 Dec 2021 Coroner: Andrew Harris Area: London Inner South Responses identified: 2 / 1 View PDF

The coroner suggests the risks of recurrent impulsive self-harm were not fully assessed in light of the circumstances, specifically concerning the period after sentencing, and that a notification form might have been completed had the risks been fully considered.

Date 22 Dec 2021
56-day deadline 16 Feb 2022 est.
Responses identified 2 of 1
Other related deaths Suicide (from 2015)

Coroner's concerns

AI summary
The coroner suggests the risks of recurrent impulsive self-harm were not fully assessed in light of the circumstances, specifically concerning the period after sentencing, and that a notification form might have been completed had the risks been fully considered.
View full coroner's concerns
The evidence suggests that his risks of recurrent impulsive self harm in situations his ex wife described as “when he is cornered” were not fully assessed as applying to the time after he was being sentenced and if they had been, a notification form might have been completed. Whether this was due to the policy requiring imminence of risk at the time of assement or being erroneously interpreted so, or whether the projection of imminence arising in a future context was not fully considered, is not clear.

Responses

2 respondents
HM Courts and Tribunals Service Central Government
3 Feb 2022 PDF
Action Planned

HMCTS is updating Security and Safety Operating Procedure 4b across all crime courts by the end of May, including publicising random searches and implementing a new Safeguarding policy with training for front line court staff to identify and escalate safeguarding concerns. (AI summary)

View full response
Dear Mr Harris, Subject: HMCTS review of risk management in respect of defendant self- poisoning I am writing, as the senior Civil Servant with overall responsibility for court and tribunal operations, to update you on the actions we have taken following the Inquest into the death of Mr Mark Castley (aka Mark Marshall). Our initial response was to conduct a thorough review of our standards and procedures aimed at managing the risk of a defendant appearing at court (having been on bail) who has secreted something on their person with the intent of self-harm/poisoning (as happened in this sad case). The review and its conclusions and recommendations (a copy of which is attached to this letter) have been endorsed by the HMCTS Senior Management Team and has followed engagement with all stakeholders, including input from the Judicial Security Committee. The Chief Magistrate is also being made aware. As part of the review, HMPPS (through its Prisoner Escort & Custody Services (PECS) team) also reviewed relevant PECS supplier standard operating procedures to ensure they align. Methodology The defendant’s journey through court was broken down into eight stages (from arriving at the front entrance, passing through security screening, public areas, into the courtroom and surrender into custody). Each stage was individually reviewed, risk assessed, and conclusions recorded. The broad approach followed was as follows:  The starting point was the identification of known potential risks and threats present at each stage.  The current baseline safety controls in place to manage the risk were then identified; this included present security policy and arrangements.  The remaining or ‘residual’ risk at each stage for self/harm the adulteration of drinking bottle (if any) was then explored. 1

 This enabled consideration of whether additional, practical and proportionate, security controls could be identified so as to manage the risk further. You will note that there are significantly different operational arrangements and significantly lower risks in the magistrates’ courts which has led to our conclusion that some of the mitigations that might be applied in the Crown Court (such as enhanced dock controls) are not necessary or reasonably practicable in the lower courts. Full details of operational and legal reasons for that position are provided in the reviewed risk assessment. That said, the review identified two additional controls which have been approved for implementation within the next few months:
1. On arrival at the front entrance Aim: To enhance HMCTS security procedures and provide a more reliable, effective level of deterrent and detection of prohibited items on the person; and to manage the risk of non-metallic prohibited items being brought into court, that could then be used as a weapon or to self-harm. Control Measure: Implementation of a random manual search requirement at the front entrance so as to (i) enhance HMCTS security procedures and provide a more reliable/effective level of deterrent and detection of prohibited items on the person; and (ii) to further reduce the risk of non-metallic prohibited items being brought into court, that could then be used as a weapon or to self-harm Random searches will be publicised on HMCTS web pages and at the court to maximise the deterrent effect. This procedure would not apply to those court users exempt from a search, such as those registered on the Professional Court User Access Scheme. We are aiming to fully implement an updated Security and Safety Operating Procedure 4b across all crime courts by the end of May. While this seems some way away, this is based on our assessment of the time we will need to undertake a number of essential enabling activities (including local site risk assessments/surveys, development and dissemination of new operating instructions, potential court security officer redeployment, and communications/engagement with court users to alert them to the changes).
2. Public Areas Aim: To enhance safety arrangements in the precincts of court buildings. Control Measure: To further enhance safety arrangements, HMCTS is currently implementing a new Safeguarding policy. This will include training, to be developed and delivered within the next few months, for front line court staff dealing with the public, such as ushers and clerks on how to identify court user safeguarding concerns more generally and how to ensure they are dealt with or escalated/communicated more effectively and consistently. We have developed the HMCTS Safeguarding policy, with PECS input, who have their own safeguarding policy/training programme for court custody staff, which is independently reviewed by Her Majesty’s Inspectorate of Prisons (HMIP). These arrangements will embed the need for effective co-ordination and co-operation between all those discharging safeguarding responsibilities at court. 2

I hope this is of assistance but we stand by to provide further information should this be required.
HM Prison and Probation Service Central Government
15 Feb 2022 PDF
Action Taken

The 'Working with Suicide & Self-Harm' guide was reviewed, changing a question about suicide risk, and the Probation EQUiP process map was updated for court staff; all London probation staff were reminded to adhere to the 'probation risk to self' EQUiP process maps. London Probation published a new thematic Suicide and Self-Harm Performance and Quality Newsletter on 19 January 2022. (AI summary)

View full response
Dear / Annwyl Mr Harris

Inquest into the death of Mr Mark Castley

Thank you for your Regulation 28 report dated 22 December 2022 following the inquest into the death of Mr Castley which concluded on the 8 December 2021. I know that you will share a copy of this response with the family and I would first like to express my sincere condolences for their loss. Following the Inquest, you raised the following overall concern; ‘The evidence suggests that his risks of recurrent impulsive self-harm in situations his ex-wife described as “when he is cornered” were not fully assessed as applying to the time after he was being sentenced and if they had been, a notification form might have been completed. Wh ether this was due to the policy requiring imminence of risk at the time of assessment or being erroneously interpreted so, or whether the projection of imminence arising in a future context was not fully considered, is not clear.’ Thank you for bringing these concerns to my attention. Upon receipt of your report a number of actions have been undertaken to address the concerns raised.
1) Appendix 1 of the ‘Working with Suicide & Self-Harm; A Guide for Probation Staff’ has been reviewed and the question ‘is there an immediate risk of suicide’ has been changed to ‘has a current concern relating to suicide risk been identified’ (staff are reminded to consider historic information which could be relevant to, or triggered by current circumstances).
2) The text above in brackets has now also been added to the Probation EQUiP process map for court staff to trigger the completion of a Suicide Risk Form where a concern has been identified. The Probation Service use a process called EQUiP which holds all national policies, processes and guidance, including process maps.
3) All probation staff in London have been reminded of the requirement to adhere to the ‘probation risk to self’ EQUiP process maps, including the completion of the Suicide Risk Form, where a current concern is identified. This directive will also be disseminated across the Probation Service nationally.

4) A new thematic Suicide and Self-Harm Performance and Quality Newsletter was published by London Probation on 19 January 2022. This has been emailed directly to all London staff in order to increase awareness of suicide prevention practice and required actions. I wish to assure you that HMPPS and the MOJ are committed to improving awareness in this area. As part of our Probation National Suicide Prevention Action Plan additional relevant actions include:
• A current project with the Zero Suicide Alliance to develop a specific online short awareness training for probation practitioners to increase knowledge and raise awareness and confidence when asking about suicide
• The introduction of an HMPPS Deaths Under Supervision Working Group to improve the way that we learn from deaths. The learning from this inquest will inform future training and suicide prevention activities in HMPPS. Thank you again for bringing your concerns to my attention. I trust this response provides assurance that action is being taken to address the matters you have raised. I conclude by once again offering my condolences to the family of Mr Castley.

Report sections

Investigation and inquest
On 12th September 2019, an inquest was opened into the death of Mark Castley, (aka Mark Marshall) who died on 26th June 2019 in St Thomas Hospital, (court ). The inquest was concluded on 8th December 2021. A jury concluded that he died by suicide, by which led to his death. It was contributed by non completion of a suicide risk form by probation officer for court staff and non confiscation by the dock officer of his which he brought into the dock impermissibly.
Circumstances of the death
The probation officer who assessed him when he was on bail, 6 days before his last appearance in court knew that he had a narciccistic personality disorder with a history of impulsive self harm. Indeed he had causing a stroke in front of police when they sought to enter his house to arrest him in 2016. She wrote in the OASYS report that his risk of suicide was greatest when police are attempting to arrest him. She did not anticipate that an act of self harm might be repeated when he surrendered bail for sentencing, but acknowledged in retrospect that she would in future consider it a risk. Even if she had she would not have filled out a suicide risk form to notify court staff as she did not consider there was an immediate risk. This appears to have been based on Appendix 1 of the NPS Guide to staff Working with Suicide, where the trigger for a stategy to prevent suicide is if the answer to the question Is there an immediate risk of suicide? is affirmative. In court she thought perhaps 50% of offenders have suicidal thoughts, but said only about once a month she filled in a suicide risk notification form. She denied she had too high a threshold for assessing imminent risk. .

Her manager did not consider that the length of sentence would be a surprise to the deceased and informed the court that if the threshold for completing a form was lower, it would catch almost all clients and not enable any priority action. She said that there was nothing in NPS records to indicate the officer should have generated a suicide risk form on 23rd April and that her decision was entirely reasonable and did not consider there was an opportunity to prevent his death as it was not foreseeable.

The manager advised that there would be variance between officers as to what was referred but the policy was not too prescriptive to avoid missing some risks. The jury concluded otherwise, identifying the policy as requiring imminence of risk.

The dock officer did not know of his past history of impulsive self harm, nor considered there was any risk of self harm or reason to

It is also evident from that this was a meticulously planned suicide with no indication of intent being disclosed, but from the suicide note, in part related to his having just received another custodial sentence: “If I die (as) I won’t ever be in custody again”.
Action should be taken
In my opinion action should be taken to prevent future deaths. Whilst the precise circumstances of this death were unique and unpredictable, there is a need for public reassurance that the projected contextutal self harm risks of those with personality disorders are recognised and mitigated, especially for those receiving less intensive assessment as they are on bail and not in custody.
Copies sent to
(MITIE Security Limited) and (PPO)

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Report details

Reference
2021-0427
Date of report
22 December 2021
Coroner
Andrew Harris
Coroner area
London Inner South

Responses identified

Responses identified 2 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 Feb 2022 (estimated).

Sent to

HM Prison and Probation Service

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