Source · Prevention of Future Deaths
Antony Coughtrey
Ref: 2018-0014
Date: 15 Jan 2018
Coroner: Thomas Osborne
Area: Milton Keynes
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified a lack of internal investigation or serious incident review by the Probation Service following the death of a released prisoner, along with procedural issues for referring prisoners back to the Parole Board after a licence breach.
Date
15 Jan 2018
56-day deadline
2 May 2018 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The coroner identified a lack of internal investigation or serious incident review by the Probation Service following the death of a released prisoner, along with procedural issues for referring prisoners back to the Parole Board after a licence breach.
View full coroner's concerns
In the circumstances it is my statutory to report to you_ that following a death of a prisoner who had been released on licence following life sentence, there was no internal investigation by the Probation Service or any inquiry resembling Serious Incident Review. seem to have led t0 an air of complacency as to the Probation Service s role in managing Mr Coughtrey I also felt there was & failure in the procedure for referring a prisoner back to the Parole Board when there had been a clear breach of the Conditions of Licence set out by the Parole Board.
Report sections
Investigation and inquest
On Gth October 2015 [ commenced an Investigation into the death of Antony Richard COUGHTREY aged 42 years_ The Investigation concluded at the end of the Inquest on the 23rd of October 2017. The conclusion of the Inquest was that Antony Richarc COUGHTREY died as a result of suicide but the went on t0 find that there was & failure to manage his Licence adequately and this had caused or contributed to his death. The medical cause of death was: a) Hanging Chronic Pancreatitis
Circumstances of the death
The circumstances of the death where that Antony COUGHTREY had been returned to prison for Breach ofhis Licence, having been released after serving 23 years of a life Scnior Coroner; The Court House Woburn Street: A MPTHILL; Bedfordshirt; MK45 ZHY Ie 0300-30u 6559 Fax 0346-300-8267 Jury sentence when he had been charged with an assault upon his brother. Once back in prison he hanged himself:
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Report details
- Reference
- 2018-0014
- Date of report
- 15 January 2018
- Coroner
- Thomas Osborne
- Coroner area
- Milton Keynes
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: 2 May 2018 (estimated from the Judiciary.uk publication date).
Sent to
- HM Inspectorate of Probation