Johnpaul Digweed

[250-word statement addressing what circumstances of the death have led to the coroner’s  concern, and why the coroner thinks the person to whom the report is directed is responsible  for taking action to prevent future deaths. This statement must not propose what action should be taken, as coroners cannot make recommendations]. 

1.   Evidence was heard that despite several staff being aware of incidents of self-harm involving a prisoner at HMP Garth an Assessment, Care in Custody Teamwork  process (ACCT) was not opened. Whilst evidence was provided that staff are trained  as part of their induction program and that training materials is available to staff, no  assurance could be given that there was any ongoing mandatory refresher training or any system in place to monitor understanding that every member of staff is  responsible for opening an ACCT where required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent  future deaths   

2.   Evidence was heard that there is a regular practice of prisoner’s covering their  observation panels in their cell doors at HMP Garth. Despite Governor’s Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not  aware of the instructions which were issued by email. As a result, the orders and  notices have been updated and reissued by email clarifying expectations in relation to  welfare checks and steps requires if observations panels are obscured. However, no  assurance could be given that staff had read and understood the instructions or that  there was any system outside the email system to ensure important information is  cascaded and seen by affected staff. In addition, whilst the amended instructions  confirm a verbal response is mandatory for welfare checks, they do not explicitly state  a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent  future deaths