Source · Prevention of Future Deaths

Charlie Todd

Ref: 2021-0318 Date: 21 Sep 2021 Coroner: James Thompson Area: County Durham and Darlington 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted the absence of a daily supervising officer in SACU, which led to ad-hoc task allocation and incomplete hourly checks, including a missed check on Mr Todd's cell. There was no real-time system to ensure compliance with these checks due to paper-based records and varying staffing levels.

Date 21 Sep 2021
56-day deadline 15 Nov 2021 stated in the report
Responses identified 1 of 1
State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary
The coroner noted the absence of a daily supervising officer in SACU, which led to ad-hoc task allocation and incomplete hourly checks, including a missed check on Mr Todd's cell. There was no real-time system to ensure compliance with these checks due to paper-based records and varying staffing levels.
View full coroner's concerns
During the course of the inquest evidence was heard from a number of witnesses of the supervision and staffing arrangements within SACU. The overall position was that there was no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed, and officers, including officers not posted to the SACU, but covering for a shift, were required to allocate various tasks between themselves on an adhoc basis. On the 2nd September 2019 the document setting out which hourly checks had been undertaken in the SACU was incomplete. No check on Mr Todd’s cell took place at 3pm that day. Evidence was heard that staffing levels can vary, with officers being occupied on tasks which meant hourly checks could not always be completed. Whilst there is auditing of the hourly checks retrospectively, there is no ‘real time’ system which would alert officers and their supervisors to checks being incomplete for a prisoner/s as the record of checks are paper based and held in the SACU, as well there is no constant supervising officer present or other system there to ensure compliance.

Responses

1 respondent

HM Prison and Probation Service

Central Government
Letter dated 15 Nov 2021 PDF
AI-classified response stance Action Taken
AI-generated response summary

• An additional officer resource and an administration staff member have been provided to support the SACU. • "Know Your Job" sheets will be provided to staff working in the SACU who are not normally based there. • The SACU Custodial Manager has been tasked with overseeing daily and weekly management checks, and a recently commissioned SACU pilot will consider operational processes.

View full response
Dear Mr Thompson

Thank you for your Regulation 28 report of 21 September 2021, addressed to the Governor of HMP Durham, following the recent inquest into the death of Charlie Todd at the prison on 2 September 2019. I am responding as Director General of Prisons.

I know that you will share a copy of this response with Mr Todd’s family and I would like to first express my condolences for their loss. Each death in custody is a tragedy and the safety of those in our care is my absolute priority.

You express concern regarding the staffing and supervision arrangements within the Separation and Care Unit (SACU), and completion of the required hourly checks.

I can assure you that there is clear management oversight of the SACU. The day-to-day running of the unit is directed by a dedicated Custodial Manager (CM), responsible for the allocation of tasks and performance management of the officers working there. The CM reports to, and is supported by, the Head of Residence and Safety (a Governor grade) who forms part of the Governor’s Senior Management Team. The running of the SACU is further subject to daily checks undertaken by the Orderly Officer and Duty Governor, and the Governor undertakes a weekly in-charge check.

I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU’s regime, and allow for the required checks to take place. The staffing of the SACU is in line with national benchmarking standards, and indeed the Governor has provided an additional officer resource, as well as an administration staff member in order to support the work of the SACU. HMP Durham have a weekly Regime Management Plan meeting which forecasts staffing levels for the following week to ensure that the regime across the prison is delivered and consistent.

It is inevitable that at some points staff who are not normally based in the SACU will be required to work on the unit for a shift, and in order to support those staff in understanding the expectations of the unit a “Know Your Job” sheet will be provided to them, setting out the tasks they will be required to cover.

Additionally, the SACU CM has been tasked with overseeing the daily and weekly management checks being carried out and will also provide an update to the Head of Residence, so that any reoccurring issues can be promptly addressed as appropriate with individual staff.

A recently commissioned SACU pilot, considering operational processes within the SACU and the management of segregated prisoners, will provide the prison with an opportunity to improve paperwork and will also be used to look at the health support provided on the unit with feedback used to strengthen current practices.

Given the number of checks that take place throughout the prison on a daily basis, implementing a ‘real-time’ system to ensure these have been done would require significant and prohibitive resource. I believe that the robust assurance processes already in place, together with the improvements made will ensure that prisoners located in the SACU at HMP Durham, can be safely managed.

Thank you again for bringing these matters of concern to my attention and for your suggestions, and I hope this provides you with the reassurances that you seek.

Report sections

Investigation and inquest
On 9th September 2019 I commenced an investigation into the death of CHARLIE BRIAN TODD, 18 years. The investigation concluded at the end of the inquest on 9th September 2021. The conclusion of the inquest was Misadventure. The medical cause of death was; 1a Pressure On Neck 1b Hanging The Jury set out their findings as; Mr Charlie Brian Todd was in HMP Durham and was admitted to SACU on 2/9/19 just after 10am that day. He was found by staff members in his cell at 16:04 hanging by a ligature around his neck. Resuscitation was commenced but was unsuccessful and unfortunately, he was pronounced dead at 1652 on 2/9/19.
Circumstances of the death
On 2nd September 2019 Mr Todd, a prisoner at HMP Durham , was subject to an adjudication hearing which resulted in him being awarded a period of cellular confinement within the Segregation & Care Unit (SACU) within the same prison. He was confined in a cell within the SACU that morning and was to be the subject to regular hourly checks. At just after 4pm the same afternoon he was discovered to have ligatured in his cell and despite efforts to resuscitate him, he died at 4.52pm that day.

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Report details

Reference
2021-0318
Date of report
21 September 2021
Coroner
James Thompson
Coroner area
County Durham and Darlington

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: 15 Nov 2021 (stated in the report).

Sent to

HMP Durham

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