UK Inquiry Tracker

Timothy Shaw

PFD Report Partially Responded Ref: 2018-0047

Date of Report 15 February 2018

Coroner Caroline Beasley-Murray

Coroner Area Essex

Response Deadline ✓ from report 3 April 2018

State Custody related deaths

Judiciary.uk Report PDF

1 of 5 responded · Over 2 years old

Sent To

HM Prison and Probation Service
Care UK Clinical Services
Essex Partnership University NHS Foundation Trust
Farleys Solicitors LLP
Phoenix Futures

Response Status

Responses 1 of 5

56-Day Deadline 3 Apr 2018

Over 2 years old — no identified published response

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

Continued……………………..  Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place.  The processes and systems for reducing access to illegal substances need to be improved and tightened up  The processes for referrals by both prisoners and staff to psychosocial services needs to be tightened up and improved.  The standard and accuracy of record keeping by both disciplinary and Healthcare staff needs to be improved.

Responses

Care UK

27 Feb 2018

Response received

View full response

Dear Madam

The inquest touching the death of Timothy Shaw Deceased HMP Chelmsford Date of death: 2 March 2017

I acknowledge receipt of your Regulation 28 Report dated 15 February 2018 to which a response is due by 3 April 2018.

As you are aware, Care UK ceased to be the providers of healthcare at HMP Chelmsford on 26 May 2017.

I have been passed the emails from Marianne Robson dated 23 February 2018 where she has advised that the PFD report was forwarded to Care UK for information purposes only and that you do not expect a response from Care UK. Accordingly we are not filing a substantive response. However, if you require any further assistance, please do not hesitate to contact me.

Report Sections

Investigation and Inquest

On 20 March 2017 I commenced an investigation into the death of Timothy John Shaw. The investigation concluded at the end of the inquest on 30 January 2018. The conclusion of the inquest was:-

Accidental death. The jury believe that with more resources and better communication further steps could possibly have been taken to manage Mr Shaw’s risk of dying and may have prevented his death.

Circumstances of the Death

Timothy Shaw, who was 34 years old at the time of his death, had a long history of offending and substance abuse. On 9 January 2017 he was remanded in custody to HM Prison Chelmsford. On 30 June 2017 he was sentenced to a 6 year imprisonment. During his time in custody he was subject to three ACCT processes. It would appear that during his time in prison, he was using drugs including prescription medication and morphine patches. On 19 February, he was found under the influence and on the morning of 28 February, he was found collapsed in his cell. He was taken to Broomfield Hospital and he died there on 2 March 2017. It would appear that no referral to the mental health service was made.