Source · Prevention of Future Deaths

Douglas Birch

Ref: 2015-0274 Date: 13 Jul 2015 Coroner: Patricia Harding Area: Mid Kent and Medway Responses identified: 1 / 1 View PDF

Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from prisoners upon cell unlocking. They also did not consistently receive or read crucial Prison Service Orders.

Date 13 Jul 2015

56-day deadline 7 Sep 2015 est.

Responses identified 1 of 1

State Custody related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response the prisoner upon unlocking a cell or were aware but did not act in accordance with the order especially where they assumed the prisoner was asleep (2) Prison officers were either not receiving Prison Service Orders and Instructions or if they did receive them, did not read them

Responses

1 respondent

HM Prison and Probation Service Central Government

13 Jul 2015 PDF

Action Taken

HMP Swaleside issued a notice to staff on 10 August 2015 setting out local procedure for welfare checks and requiring staff to sign to confirm checks have taken place. NOMS is compiling a learning bulletin for all staff on their intranet by the end of September. (AI summary)

View full response

Dear Ms Harding; RE: Regulation 28 report concerning the inquest into the death of Douglas Birch on 15 2013 at HMP Swaleside: Thank you for your report addressed to the Governor of HMP Swaleside, dated 13 July 2015, concerning the inquest into the death of Douglas Birch: Your report has been passed to Equality, Rights and Decency Group in the National Offender Management Service (NOMS) for response, as we have responsibility for sharing learning from all deaths in prison custody in England and Wales. The two concerns you raise in your report are as follows: Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response from the prisoner upon unlocking or were aware but did not act in accordance with the order especially where assumed the prisoner was asleep. (ii) Prison officers were either not receiving Prison Service Orders or Instructions or if did receive them, did not read them: It is not reasonable to expect all prison staff to read all Prison Service Orders and Instructions_ Rather, it is the responsibility of the Governor of each prison establishment to bring relevant instructions to the attention of staff and to ensure that are reflected in local policies and procedures_ In response to your concerns, the attached notice to staff was issued at HMP Swaleside on 10 August
2015. It sets out the local procedure for ensuring compliance with the mandatory requirement in PSI 75/2011 to which you refer, and requires staff and supervising officer to sign to confirm that the welfare checks have taken place on each occasion May cell they they they

In order to ensure that the importance of welfare checks is better understood across the prison estate, NOMS is compiling learning bulletin that will be published for the attention of all staff on our intranet by the end of September. hope this provides assurance that your concerns have been addressed locally and that action has been taken to ensure that the requirement to undertake welfare checks is better understood in all prisons in England and Wales_

Report sections

Investigation and inquest

On May 2013 | commenced an investigation into the death of Douglas Birch, 46. investigation concluded at the end of the inquest on gth July 2015. The conclusion of the inquest was that Douglas Birch died in his bed at HMP Swaleside between the hours of 19.10 on 14"h May 2013 and 07.10 on 15" May 2013 of sudden arrhythmic death syndrome: He was found at 12.20 on 15th May 2013 by prison officers

Circumstances of the death

Douglas Birch was a serving prisoner at HMP Swaleside in a single occupancy cell: On 15th May 2013 after a roll call at 7.10, the cells were unlocked at 08.15 for 30 minutes domestics before locked again at 08.45_ cells were unlocked at approximately11.35 for lunch and locked again at approximately 12.10. His dead body was not discovered until 12.20 after a prison officer who had delivered mail to his cell without receiving a response raised concerns with a senior officer and the cell was entered. The state of his body was such that it could be established that he had been dead for a number of hours and likely before 08.00. No officer responsible for locking or unlocking his cell had sought to elicit a response from believing him to be asleep at the time. This was in contravention of PSI 75/2011

Action should be taken

In my opinion action should be taken to prevent future deaths and believe_you have the 22nd The being The him, from power to take such action_

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2015-0274
Date of report: 13 July 2015
Coroner: Patricia Harding
Coroner area: Mid Kent and Medway

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: 7 Sep 2015 (estimated).

Sent to

HMP Swaleside

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.