Andrew Frere
PFD Report
Unknown
No published response · Over 2 years old
Response Status
Responses
0
56-Day Deadline
3 Nov 2015
Over 2 years old — no identified published response
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Source: Courts and Tribunals Judiciary
Coronerysconcerns
taken. In the circumstances it _ 0b Prison Service Instruction 64/2011 requires that prisoners under continuous Otsengaeorisdoulc be seen by a doctor very 24 hours The evidenccogivetoats theonquest indicated that this was not practicable, and the rule was widely recognised as not being so practicable; Mi concerniis less or to the apparent impracticability of the PSI, but more that, this impracticability having been recognised, the rule appears to have been ignoreditatheri than any attempt having been made at least to comply as hs possibleinSince Andrew Frere s death this iS now donesato-CP Mooriacldbely having nursing staff see the prisoner When a doctor is not available; botrthec by problem with the impracticability of the PSI appears to be national, rather tnan local one, and ought to be the subject of some sort of guidance at natioeal level, (2) The PSI does not appear to include any specific instruction that the case manager; or others attending ACCT review; should ensure that read the ongoing observations, at least as far back as the previous review; in order te ensure that are aware of recent events when cary out such a review_ taveconcern is that potentially important information, which might affect decisions taken at the review, may be missed if the recent observations are not read Coroner's Court and Office Doncaster Crown Court; Road, Doncaster; DNI 3HS Tel 01302 320844 Fax 01302 364833 during the The they' they they - College
Action Should Be Taken
In my opinion action should be taken to prevent deaths and believe you have the to take such action. power
Report Sections
Investigation and Inquest
On 13/02/2014 commenced an investigation into the death of Andrew Douglas Frere, 34 The investigation concluded at the end of the inquest on 08 September 2015. The conclusion of the inquest was that he took his own life whilst the balance of his mind was disturbed.
Circumstances of the Death
On 1g" January 2014 Andrew Frere self harmed whilst a prisoner at HMP Moorland, Doncaster: He was placed on an ACCT, which remained open and which was subject to 11 reviews under the ACCT procedure until 10 February 2014,when he died as a result of suspending himself by a ligature formed a bedsheet in his cell He was initially placed on continuous observation and for this purpose was moved the houseblock where he was located to a gated cell in the Induction He was diagnosed as suffering depression with some svchotic features, and appeared in particular to have concerns about retuming to reside on the houseblock and about which would happen following his forthcoming release from prison , As regards the former concern; although he clearly felt more comfortable on the Induction Wing; it was recognised that long-term residence on that wing was not practicable, and that he would have to be reintegrated onto the houseblock at some point; It was also recognised that it was undesirable for him to remain under constant observation for any longer than was necessary: Andrew Frere appears to have made good progress under the ACCT, but the improvement was not without setbacks which he felt low in mood and expressed suicidal ideation. Those were appropriately recorded in the ACCT ongoing record. Coroner's Court and Oflice Doncaster Crown Court; Collcge Road; Doncaster; DNI 3HS Tel 01302 320844 Fax 01302 364833 Group; House, Petty from from Wing: from during "
At the ninth review, held on 31 January 2014 the level of observation reduced to one per hour; Atthe tenth review; on 4 FebruanyZ01vatiowagas decided to move him back to his cell in the houseblock At the eleventh on February 2014, this level of observation was further reducedeteg review, hours He hanged himself in his cell a short period when per 24 locked up for lunch; between 12.30 pm and 1.30 pm: prisoners were
At the ninth review, held on 31 January 2014 the level of observation reduced to one per hour; Atthe tenth review; on 4 FebruanyZ01vatiowagas decided to move him back to his cell in the houseblock At the eleventh on February 2014, this level of observation was further reducedeteg review, hours He hanged himself in his cell a short period when per 24 locked up for lunch; between 12.30 pm and 1.30 pm: prisoners were
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.