Wayne Boughen

PFD Report All Responded Ref: 2021-0217
Date of Report 23 June 2021
Coroner James Hargan
Response Deadline est. 18 August 2021
All 1 response received · Deadline: 18 Aug 2021
Sent To
Response Status
Responses 1 of 1
56-Day Deadline 18 Aug 2021
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns
1. At the time of Wayne Boughen’s death, HMP Leeds did not have any cells which were certified safer cells (anti-ligature cells) in accordance with national standards.
2. HMP Leeds still does not have any such certified safer cells.
3. HMP Leeds has a small number of cells which have an increased level of safety as compared with the majority of cells within the prison, but even they do not comply with the certified safer cell standard.
4. In an ordinary cell, Wayne Boughen was able to suspend himself using a ligature fashioned from a prison issue jumper.
Responses
HMPPS
13 Aug 2021
Response received
View full response
Dear Mr Hargan Thank you for Regulation 28 report of 23 June 2021, addressed to the Governor of HMP Leeds, following the recent inquest into the death of Wayne Boughen at the prison on 17 November 2018. I am responding as Director General for Prisons. I know that you will share a copy of this response with Mr Boughen’s family and I would like first to express my condolences for their loss. Each death in custody is a tragedy and the safety of those in our case is my absolute priority. During the inquest, evidence was given that at the time of Mr Boughen’s death HMP Leeds did not have any certified safer cells which met the national published standard and that this position remained unchanged. You were concerned that although the prison has a small number of cells which have an increased level of safety, these still did not comply with the certified standard. You note that Mr Boughen was located in an ordinary cell when he died. I fully appreciate your concerns and would like to reassure you that we are committed to ensuring that prisoners in our care, particularly those who are considered to be at a risk of suicide or self-harm, are located in the safest environment possible. We recognise that cell safety is an important part of managing prisoners at risk, and wherever possible new builds and major refurbishment projects are delivered to the published safer cell specification. However we also know that placing someone who has been identified as being at risk in a safer cell that is fully compliant with the standard does not fully eliminate that risk. We therefore believe that whilst safer cells can be of assistance, they are not sufficient on their own to protect prisoners. Many older establishments, including HMP Leeds, are built in a way that it makes it impossible to refurbish most cells in a way that fully meets every aspect of the safer cell specification. For this reason there is no requirement in our policy for prisons to have, or to use, safer cells. Nonetheless the Governor of HMP Leeds is committed to improving the safety of the available accommodation where possible, and will continue to work with Amey, the maintenance contractor, to identify opportunities for further work to reduce the availability of ligature points in cells.

We believe that the best way to protect prisoners at risk is through the individualised, multi­ disciplinary case management provided by the Assessment, Care in Custody Teamwork (ACCT) process https://www.gov.uk/government/publications/managing-prisoner-safety-in­ custody-psi-642011 Since the inquest a revised version of the ACCT has been fully introduced across the male estate, including at HMP Leeds. All staff at the prison have received awareness training specific to their roles and responsibilities and to highlight the key changes to the procedures. Some of the improvements made to the ACCT document are designed to lead to a better standard of record keeping and to ensure that key risk information is highlighted more clearly on a form that is updated throughout the process and encourages more meaningful interaction with prisoners at risk. An individualised assessment, considering risks, triggers and protective factors, is completed and used to produce an appropriate care plan setting out the support being offered to the individual concerned. This includes consideration of the prisoner’s location, and the option to remove or restrict access to items that may be used as ligatures and/or the provision of alternative clothing. If risk is considered to be very high, levels of observation can be increased, and for those in acute crisis, constant supervision can be deployed. Implementation of the new version of ACCT at HMP Leeds is being monitored carefully by the Governor and safety team, with regular feedback to managers and individual staff highlighting any need for improvement and good practice where appropriate. I am confident that these measures will improve the operation of the ACCT process at HMP Leeds. Thank you again for bringing these matters of concern to my attention. I hope this provides assurance that whilst the situation with regard to the availability of safer cells remains unchanged, the measures that have been taken to improve the ACCT system, and to ensure that the revised version is fully implemented at HMP Leeds, will ensure that prisoners identified as being at risk of self-harm and suicide are safely managed.
Report Sections
Investigation and Inquest
On 21st November 2018, Senior Coroner, Kevin McLoughlin commenced an investigation into the death of Wayne Boughen, aged 40. The investigation concluded at the end of the Inquest on Thursday 3rd June 2021. The conclusion of the Inquest was that Wayne Boughen deliberately suspended himself with a ligature around his neck, but the jury were unable to determine his intention in doing so. The medical cause of death was 1a. hypoxic-ischaemic encephalopathy, 1b. hanging.
Copies Sent To
1. , Practice Plus Group 4. , Uncle 5. , Ex Lord Chancellor Secretary of State for Justice, The Rt Hon Robert Buckland QC MP
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.