Jason Williams: Prevention of future deaths report

On 31st July 2020 Jason’s cell door was unlocked by prison staff at 14.14 hours however a welfare check was not conducted upon unlock. It cannot be established that this had any causative or contributory bearing on Jason’s death.

i  JASON’S HISTORY OF MISUSE OF DRUGS
 
Jason’s history of misuse of drugs probably caused or contributed more than minimally to his death. Jason had a habitual drug habit that was documented on assessment on entering HMP Guys Marsh and throughout his custodial sentence.
 
ii  JASON’S VULNERABILITY

We are satisfied that Jason’s vulnerability possibly contributed to his death more than minimally. Jason’s drug dependency in Prison contributed to his vulnerability due to his apparent willingness to take illicit substances.

iii  THE DRUG PREVENTION STRATEGIES IN THE PRISON IN JULY 2020

The restrictions imposed in July 2020 due to Covid, impacted the execution of the drug prevention strategy. This possibly contributed more than minimally to Jason’s death.
iv. THE MEASURES TAKEN BY THE PRISON FOLLOWING THE SUSPECTED THROWOVER ON 25TH JULY 2020
v THE STEPS TAKEN BY THE PRISON, AND/OR ISMS TO SAFEGUARD JASON FOLLOWING THE SUSPECTED THROWOVER ON 25TH JULY 2020 AND ONCE HE WAS FOUND TO BE UNDER THE INFLUENCE OF PS ON 30TH JULY 2020

No specific instruction was given to staff relating to Jason following the suspected throwover of illicit items and the increase of psychoactive substance incidents around this time. Nor were there any additional briefings to prison officers or notices distributed to prisoners. This possibly contributed more than minimally to Jason’s death.
This could be constituted as a safeguarding failure towards Jason from the steps taken by the Prison.

All staff who have contact with an offender and who have access to Prison-NOMIS must update case notes on a regular basis.

In the NOMIS case notes for Jason there did not appear to be regular entries from Prison staff. For example, between the entry on the 19th March 2020 and 7th June 2020 there was no record by prison staff who had contact with Jason on the wing. Whilst it is noted this was when the Covid 19 pandemic began, this was a time when there should have been increased monitoring and recording due to the fact activities were suspended and there was less general contact with prisoners from others outside the wing.

Information was provided that Prison staff have access to PSI 23/2014, they are provided with the Prison Officers’ Guide produced by HMPPS and they are provided with training on record keeping at the Prison Officer Entry Level Training (POELT) training.  There is no refresher training  at  HMP Guys  Marsh  on
record  keeping,  or  the  importance  of  it  other  than  to cover information sharing.

Evidence was given as to the importance of triangulation of communication and care between the prison, healthcare and ISMS staff. Healthcare and ISMS have access to the NOMIS records as well as the prion staff and this is therefore the key record for information sharing about a prisoner, their risks and vulnerabilities.
 
iv. Governor notices can be sent to prison staff and  prisoners to  advise them of any matters, including when there are warnings to be given to prisoners. In the past at HMP Guys Marsh, Governor notices have been sent out when there has been a spike in psychoactive substance incidents. There was no Governor notice sent out between the 25th July 2020, when there was a suspected throw over of illicit items into the prison, and the 3rd August 2020. Over this period of 9 days there were 106 recorded psychoactive substance attacks which was described in evidence as an incredibly high number. Evidence was given that these notices are issued at the discretion of the Governor.
 
2.     I have concerns with regard to the following:

i.         There is a lack of specific and dedicated national guidance to prison and healthcare staff on how to define and care for vulnerable prisoners. I would request that consideration is given to producing national guidance on this, to also include guidance on addressing self-neglect.

ii.          The current keyworker programme is not working as planned at HMP Guys Marsh and there was reference to this also being reflected nationally. I would request that consideration is given to a review being undertaken of the keyworker programme within the whole prison estate, and also specifically at HMP Guys Marsh.
 
iii.          The quantity and quality of record keeping by prison staff at HMP Guys Marsh on NOMIS. I request that consideration is given to providing refresher training to prison staff on record keeping to cover the importance of records and their contents, and the required regularity of recording.

A Governor notice was not issued in the time leading up to Jason’s death to prisoners or staff around the concerns regarding access to, and the impact of using, psychoactive substances. I request that consideration is given to a review being undertaken by HMP Guys Marsh as to when such notices should be issued, particularly in relation to increased risks to prisoners around drug use.

I am also under a duty to send the Chief Coroner a copy of your response.
I have also provided copies to the following who I believe this report will be of interest to:
(1)  Hill Dickinson LLP on behalf of Oxleas NHS Foundation Trust
(2)  Hill Dickinson LLP on behalf of Change Life Grow
  
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.