Source · Prevention of Future Deaths

Paul James

Ref: 2018-0254 Date: 27 Apr 2018 Coroner: Christopher Sutton-Mattocks Area: Mid Kent & Medway Responses identified: 1 / 2 View PDF

A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and safety protocols for vulnerable individuals.

Date 27 Apr 2018
56-day deadline 20 Nov 2018 est.
Responses identified 1 of 2
State Custody related deaths

Coroner's concerns

AI summary
A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and safety protocols for vulnerable individuals.
View full coroner's concerns
This was a prisoner with a known history of serious self harm even before 8/7/16. On that day he had used razor blades to inflict very serious injuries to himself. He was known to have ceased taking his prescribed medication. He was placed in a single cell and permitted access to razor blades again. Following Mr James being found dead in his cell on 20/12/16 three razor blades were found by , Kent Police, in a search of the cell. The blades had been used to make nine tentative cuts to the abdomen followed by a 17 cm cut. His intestines were exposed on the bed alongside him. The consultant pathologist,

, gave evidence that he had died as a result of loss of blood over a period of approximately 20 minutes.

The Matters of Concern

That Mr James was given access to razor blades in all the circumstances.

Action to be taken Practical difficulties in restricting the supply of razor blades were raised in evidence by the . They included the following:- razor blades are handed out for reasons of personal hygiene, that they are available from the canteen, that they could be obtained from other prisoners, that other sharp instruments might be used instead and that serious self harm with the use of razor blades is rare.

Action that should be taken to prevent future deaths. There should be further investigation and research undertaken to develop protocols and procedures to deny prisoners access to razor blades in the rare circumstances in which a prisoner is known to have seriously self harmed with the use of razor blades in the past, and especially when it is known that he/she has self harmed on other occasions

C J SUTTON-MATTOCKS Assistant Coroner for the County of Kent

27/4/18

Responses

1 respondent
HM Prison Probation Service Central Government
31 Oct 2018 PDF
Action Planned

HM Prison & Probation Service will issue a learning bulletin on managing razor blade risks, pilot a revised ACCT case management process prompting consideration of razor blade access, and consider broader options for managing the issue. (AI summary)

View full response
Dear Mr Sutton-Mattocks

Thank you for your Regulation 28 Report of 9 April 2018 following the recent inquest into the death of Paul James at HMP Elmley on 20 December 2016.

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

Your concern is the availability of razor blades to prisoners with a history of self-harm by using them, and you have suggested that further investigation and research is undertaken to develop protocols and procedures to deny prisoners access to razor blades in these circumstances.

I understand that you were made aware during the inquest that as part of the requirement to have safe systems of work in place, there is an expectation that measures will be in place at each prison to assess and manage the risk posed by the availability of disposable razors as a means of self-harm. This was most recently re- enforced in a letter from Phil Copple, the Executive Director of Prisons, to Governors in April 2018.

In response to your concerns, we are taking a number of further actions. First, we will be issuing a learning bulletin within the next few weeks that draws on the example of this case to re-emphasise the risk presented by access to razor blades

and provides further guidance on how to manage them. Second, early in 2019 we will be piloting a revised version of the ACCT case management process for prisoners at risk of self-harm and suicide, and we will ensure that the revised documentation that is being introduced prompts case managers specifically to consider the risks associated with razor blades, and whether or not it is appropriate to take steps to restrict access, as part of each individual case review. Finally, the Prison Safety Team is giving further consideration to a broader range of options for managing this issue, including the practicality of further controls on access and the availability of safer alternatives to disposable razors.

Thank you again for bringing these matters of concern to my attention. I hope that this response provides reassurance that learning from this tragic incident is being shared widely across the prison estate.

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Report details

Reference
2018-0254
Date of report
27 April 2018
Coroner
Christopher Sutton-Mattocks
Coroner area
Mid Kent & Medway

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Nov 2018 (estimated).

Sent to

HMP Elmley
THE SECRETARY OF STATE FOR JUSTICE

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