Source · Prevention of Future Deaths

Trevor Oakley

Ref: 2019-0495 Date: 26 Nov 2019 Coroner: Samantha Marsh Area: Hampshire Responses identified: 1 / 1 View PDF

Night staff at the prison may not be immediately aware of which prisoners are due in court the following morning, potentially overlooking increased self-harm risks among these prisoners.

Date 26 Nov 2019

56-day deadline 21 Jan 2020 est.

Responses identified 1 of 1

State Custody related deaths

Coroner's concerns

AI summary

Night staff at the prison may not be immediately aware of which prisoners are due in court the following morning, potentially overlooking increased self-harm risks among these prisoners.

View full coroner's concerns

(1) I was told that the Courts will supply the Prison with a list of prisoners who are required for trial the following day, ("the List"). The List is circulated within the prison by the OMU (Offender Management Unit) and the overnight staff should receive the List to enable them to know which particular prisoners need to be unlocked for Court attendances the following day. I was told that the Night Orderly Officer will brief the night shift officers on the wings as to what is due to be happening over the course of the night shift, but it was the evidence of more than one Prison Officer on duty that there was no notification of the prisoners due in Court the next morning. The stance adopted within the prison appeared to be that the information was available if a Prison Officer wanted to go and look for it within the system.

(2) I am concerned that within the Prison it is not immediately apparent to the night staff who is due in Court the following morning an from this, it flows, that any increased risk of self-harm by such prisoner(s) is not identified.

Responses

1 respondent

Wye Valley NHS Trust NHS / Health Body

PDF

Action Planned

• The use of thromboprophylaxis to surgery has been relaunched and clarified to all pertinent staff, particularly the time period before which it should be withheld. • All speciality specific thromboprophylaxis guidelines are being reviewed. (AI summary)

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Dear We stay Tues July

Although not actually the root cause for this patient's death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis to surgery, particularly the time period before which it should be withheld. In addition to and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and would be happy to update you on the progress of this a later date_ trust this answers all the outstanding questions you have for this sad case but would be more than happy to meet with you in person to clarify any other details. Best wishes

Report sections

Investigation and inquest

On 30th October 2018 I commenced an investigation into the death of Trevor Albert Oakley, who was 74 years old. The investigation concluded at the end of the inquest on 23rd October 2019. The conclusion of the inquest was that Mr Oakley's death was due to suicide, with a medical cause of death as: 1a. Ligature suspension.

Circumstances of the death

At 06:26 hours on the Twenty-second of October 2018 Trevor Albert Oakley was found hanging from the window bars in his cell. He had suspended himself from a ligature made of a bedsheet. He was hidden behind a non-prison issue 'privacy curtain'. He was pronounced deceased at 06:50am by attending paramedics. Mr Oakley was due to start his Trail at Salisbury Crown Court that morning (the 22nd October 2018) for serious sexual offences.

Mr Oakley was remanded to HMP Winchester on the 14th February 2018. Prior to his remand he had taken an intentional overdose of insulin and prescription mediation on the 28th January 2018; being the day that officers from Hampshire Police had attended to arrest him on suspicion of committing the sexual offences for which he was ultimately due to stand trial. He was hospitalised for 8 days and on discharge from hospital was admitted to a psychiatric ward. On discharge from the psychiatric ward he was arrested and on appearing before Basingstoke Magistrates Court on the 14th February 2018 he was remanded into custody.

Mr Oakley had three ACCTS opened whilst he was in prison; the last of which was opened on the 8th August 2018 and closed the following day, namely the 9th August2019. This related to issues of alleged bullying of Mr Oakley by his cellmate. Between August and the date of his death there was no involvement of mental health.

On the 22nd October 2018 Mr Oakley was due to start his trial. I head evidence that he would have been aware of this date, most likely via his legal representative, and the trial would have been the first time he would have faced his family since they had made serious allegations against him for sexual assault (of his daughters and grandchildren). I heard evidence from witnesses within the Health Service at the Prison that Mr Oakley had a pattern of being unwell on the occasions when he was due to attend Court, and so 7 the start of his trial is likely to have been a stressful time for him.

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Report details

Reference: 2019-0495
Date of report: 26 November 2019
Coroner: Samantha Marsh
Coroner area: Hampshire

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: 21 Jan 2020 (estimated).

Sent to

HM Prison and Probation Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.