Source · Prevention of Future Deaths

Vincent Oliver

Ref: 2014-0438 Date: 9 Oct 2014 Coroner: Tony Brown Area: Northumberland (North) Responses identified: 1 / 1 View PDF

A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance with physical response requirements during roll checks, risks missed deaths.

Date 9 Oct 2014

56-day deadline 5 Dec 2014

Responses identified 1 of 1

State Custody related deaths

Coroner's concerns

AI summary

A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance with physical response requirements during roll checks, risks missed deaths.

View full coroner's concerns

The prison officer unlocking Mr Oliver’s cell on 4th July 2013 at approximately 5.40 p.m. for the evening meal did not check on his physical well-being by getting a response from him, before moving on to the next cell. This led to Mr Oliver, who had died some time earlier and was affected by rigor mortis, being found by another prisoner when he entered Mr Oliver’s cell.

There has been a number of other occasions at the prison when appropriate cell unlocking procedures have not been followed and the Prisons and Probation Ombudsman has made recommendations about this previously.

I understand that a Prison Director’s Order has been issued requiring that on roll check Prison Officers must obtain a response from each prisoner to ensure their physical presence and well-being. My understanding of the procedures is that there is no current requirement for the Officer completing the roll check to record on the roll check report that he or she has complied with the requirements of the above Order.

Responses

1 respondent

HM Prison and Probation Service Central Government

PDF

Action Taken

HMPS Northumberland has introduced a written system for recording wellbeing checks of prisoners throughout the day, with wing diaries amended to reflect the change. (AI summary)

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Dear Mr Brown, Regulation 28 Report concerning the inquest into the death of Vincent Oliver on 4th July 2013 at HMP Birmingham Thank you for your report addressed to the Director dated October concerning the inquest into the death of Vincent Oliver who died at HMP Northumberland on 4th July 2013_ Your letter has been passed to Equality Rights and Decency Group in the National Offender Management Service (NOMS) , to respond to as we are responsible for the policy on suicide prevention and self- harm management and for sharing learning from deaths in custody You raised concerns at the inquest about staff receiving responses from prisoners when are unlocked: PSI 75/2011 Residential Services at chapter 2.3 offers the following guidance_ "The appropriate arrangements will depend on the local regime, but there need to be clearly understood systems in place for staff to assure themselves of the well of prisoners during or shortly after unlock: For example, if prisoner is expected to leave their cell for an activity shortly after being unlocked, then it will be sufficient for there to be a check on any prisoner who does not do so_ Where prisoners are not necessarily expected to leave their cell, staff will need to check on their well-being, for example by obtaining response during the unlock process_ In order to address this issue HMPS Northumberland have introduced system for recording in writing that wellbeing checks of prisoners have taken place throughout the day: The wing diaries have been amended to reflect the change and the system was in place from Sunday 16th November 2014 attach copies of the relevant Director's Order and Notice to Prisoners

Report sections

Investigation and inquest

On 4th July 2013 I commenced an investigation into the death of Vincent Oliver, age 50 years. The investigation concluded at the end of the inquest on 29th September 2014. The conclusion of the inquest was that Vincent Oliver died from natural causes, the medical cause of death being:-

1a Ischaemic Heart Disease 1b Coronary Artery Atheroma

Circumstances of the death

Vincent Oliver was serving a term of imprisonment at HMP Northumberland. A roll check was carried out at 4.00 p.m. on 4th July 2013 and Mr Oliver was recorded as present. At approximately 5.40 p.m., shortly after the cells were unlocked, the lifeless body of Vincent Oliver was discovered in his cell by a fellow prisoner.

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Shared signals

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Report details

Reference: 2014-0438
Date of report: 9 October 2014
Coroner: Tony Brown
Coroner area: Northumberland (North)

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: 5 Dec 2014.

Sent to

HMP Northumberland

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.