Source · Prevention of Future Deaths
Lee MacPherson
Ref: 2014-0097
Date: 3 Mar 2014
Coroner: Elizabeth Pygott
Area: London (West)
Responses identified: 0 / 4
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Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
Date
3 Mar 2014
56-day deadline
28 Apr 2014 est.
Responses identified
0 of 4
Coroner's concerns
Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
View full coroner's concerns
(1) The police risk assessment was not completed until the deceased had already been collected by SERCO and it was a police risk assessment completed in the early hours of the morning that found its way to the prison.
(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER_ Boxes on the PER had been ticked indicating that; among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents
(3) The escort handover details on the PER were not completed by the prison staff (or SERCO staff which is a matter SERCO have already addressed): The PER and accompanying risk assessment are of crucial importance when persons in custody are escorted from one place to another: Although these matters were not material t0 the outcome in this particular case it could well give rise t0 problems in the future.
(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER_ Boxes on the PER had been ticked indicating that; among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents
(3) The escort handover details on the PER were not completed by the prison staff (or SERCO staff which is a matter SERCO have already addressed): The PER and accompanying risk assessment are of crucial importance when persons in custody are escorted from one place to another: Although these matters were not material t0 the outcome in this particular case it could well give rise t0 problems in the future.
Report sections
Investigation and inquest
On 22 October 2012 an inquest was opened into the death of Lee Sean MACPHERSON aged 46 The inquest concluded on 3 March 2014. The conclusion was that the medical cause of death was unascertained and the conclusion was open the evidence did not fully or further disclose the means whereby the cause of death arose.
Circumstances of the death
On 17 October 2012 the deceased was found dead in his cell; a safer custody cell, on the First Night Centre at HMP Wormwood Scrubs_ He had been remanded into custody the afternoon before having been arrested on 15 October; held in police custody at Heathrow Police Station overnight, conveyed by SERCO to Uxbridge Magistrates' Court and from there to prison. He had a longstanding history of paranoid schizophrenia which was partially treated by medication.
Action should be taken
In my opinion action should be taken t0 prevent future deaths and believe your organisations have the power to take such action:
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Report details
- Reference
- 2014-0097
- Date of report
- 3 March 2014
- Coroner
- Elizabeth Pygott
- Coroner area
- London (West)
Responses identified
Responses identified
0 of 4
4 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Apr 2014 (estimated).
Sent to
- HMP Wormwood Scrubs
- Metropolitan Police
- National Offender Management Service
- Serco