Source · Prevention of Future Deaths

Brett Marrs

Ref: 2020-0179 Date: 23 Sep 2020 Coroner: Nicholas Rheinberg Area: Lancashire and Blackburn with Darwen Responses identified: 0 / 1 View PDF

Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.

Date 23 Sep 2020
56-day deadline 19 Nov 2020
Responses identified 0 of 1
State Custody related deaths

Coroner's concerns

AI summary
Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.
View full coroner's concerns
1. Two long-serving prison officers who gave evidence at the inquest deposed to the fact that they had never been given first-aid training, including training in resuscitation techniques, during their service as prison officers despite the fact that prior to 2016 such training was meant to form part of core training for prison officers. Evidence was further given that first aid refresher training is to be rolled out but that no date has yet been fixed for completion of such training programmes. These matters are drawn to your attention so that you might consider: (a) Identifying any further officers who have never been given first aid training and rectifying this deficiency (b) Setting a target date for completing refresher training.

2. CCTV footage viewed at the inquest showed a prison officer conducting a first morning cell unlock on C wing without conducting even the most basic of welfare checks and this despite clear notices from management drawing to the attention of staff the necessity of carrying out welfare checks, particularly at the time of the first morning unlock. Evidence was heard to the effect that this was not an isolated instance. Given that notices and reminders appear not to have achieved uniform obedience, you are asked to consider how better compliance with welfare checks can be achieved.

Report sections

Investigation and inquest
On 17th September 2018 an investigation into the death of Brett Anthony Marrs aged 40 was commenced. The investigation concluded at the end of the inquest on 22nd September 2020. The conclusion of the inquest was that the death of Brett Anthony Marrs who died as a result of synthetic cannabinoid and morphine toxicity was drug related.
Circumstances of the death
The deceased who was a long-term drug user was found collapsed in his cell after morning unlock on 4th September 2018. The officer unlocking the cell had not checked on the welfare of the deceased and the two officers who commenced resuscitation had not had any first aid training during their time in the prison service.

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Report details

Reference
2020-0179
Date of report
23 September 2020
Coroner
Nicholas Rheinberg
Coroner area
Lancashire and Blackburn with Darwen

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Nov 2020.

Sent to

HMP Wymott

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