Source · Prevention of Future Deaths

Wesley Rowlands

Ref: 2020-0195 Date: 5 Oct 2020 Coroner: Nicholas Rheinberg Area: Lancashire and Blackburn with Darwen Responses identified: 1 / 1 View PDF

Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.

Date 5 Oct 2020
56-day deadline 2 Dec 2020
Responses identified 1 of 1
State Custody related deaths

Coroner's concerns

AI summary
Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.
View full coroner's concerns
ln the circumstances it is my statutory duty to report to you. as fottows. ­ A number of cells at HMP Garth, including the deceased's cell, have television brackets built into the structure of the cellwalls. Although the brackets are now redundant, they remain in place and constitute a gross and obvious ligature point and will continue to do so until removed. h

Responses

1 respondent
HMP Garth Prison / Probation
26 Nov 2020 PDF
Action Planned

HMP Garth has arranged for the Prison Maintenance Group to review all cells and remove unused television brackets, with completion expected by February 2021. They are also reviewing accommodation in other prisons and alerting Prison Group Directors and Governors to the concerns. (AI summary)

View full response
Dear Mr Rheinberg Thank you for Regulation 28 report of 5 October 2020, addressed to the Governor at HMP Garth, following the recent inquest into the death of Wesley Rowlands at the prison on 14 October 2016. I am responding as Director General of Prisons. I know that you will share a copy of this response with Mr Rowland’s family and I would like first to 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. During the inquest, evidence was given that a number of cells at HMP Garth have television brackets, which are no longer in use, built into the structure of the cells walls, and you have expressed concern that unless removed they will continue to present a potential ligature point. Please be assured that this is an issue that we take very seriously, and arrangements have already been made by our Prison Maintenance Group to review all cells at HMP Garth and to remove the brackets. This work was delayed by the restrictions that we implemented in response to the pandemic, but I can confirm that it will be completed by February 2021. We are seeking also to address any similar risks in other prisons by reviewing all accommodation of the same type, and looking back at reported self-harm incidents, so that we can identify and remove any other unused brackets that offer ligature points. We will also alert Prison Group Directors and Governors to the concerns that you have reported, so that they are aware of the importance of identifying unused brackets and taking prompt action to remove them. Your concerns will inform our decisions relating to future prison capacity and our approach on new prison builds, including house block expansion designs. Our new prison design, which is being used for HMP Five Wells, the new prison at Glen Parva and four other new prisons, includes cells that will be finished to a ‘safer cell’ standard, meaning that ligature points have been designed out as far as possible and other design and construction

measures have been taken to minimise the instances of self-harm. A number of observation cells have also been placed in each of the houseblocks and Care & Separation Units (CASU) so that prisoners who have been identified as at immediate risk of self-harm can be monitored and managed appropriately. These cells will be used alongside the support provided to a prisoner from staff, healthcare providers and other partners. In addition, cells have been designed to reduce ‘blind spots’, enabling staff to check and confirm the wellbeing of prisoners more effectively. Thank you again for bringing these matters of concern to my attention. We will ensure learning from this tragic incident is taken forward.

Report sections

Investigation and inquest
On 25th July 2017 an inquest into the death of Wesley Dennis Rowlands was opened. The investigation concluded at the end of the inquest on 2nd october 2020. The conclusion of the inquest was that Wesley Dennis Rowlands died by suicide as a result of ligature hanging.
Circumstances of the death
The deceased ended his life by hanging. According to notes left in his cell at HMP Garth the deceased was filled wlth remorse for harm that he had inflicted on others. The deceased had used a fixed television bracket as a liqature bracket. tr CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern ln my opinion there is a risk that future deaths will occur unless action is taken. ln the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as fottows. ­ A number of cells at HMP Garth, including the deceased's cell, have television brackets built into the structure of the cellwalls. Although the brackets are now redundant, they remain in place and constitute a gross and obvious ligature point and will continue to do so until removed. h ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

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Report details

Reference
2020-0195
Date of report
5 October 2020
Coroner
Nicholas Rheinberg
Coroner area
Lancashire and Blackburn with Darwen

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: 2 Dec 2020.

Sent to

HMP Garth

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