In the circumstances it is my statutory duty to report to The MATTER OF CONCERN is as follows The conclusions of the investigations by the Prisons and Probation Ombudsman led to a suitable action plan being implemented at HMP Featherstone in matters relating to violence reduction, discharge from mental health team and barricade incidents_ At the incident when Christopher died initially a hydraulic jack to open the cell door was summoned to the scene when the appropriate equipment was a hooligan bar (it did in fact arrive soon afterwards): am aware that there is a gradual process in the prison estate to move towards cell doors that can be opened outwards if from you: very necessary in addition to normally opening inwards_ My concern however is that for doors that are not dual opening prisons should have appropriate equipment available to deal with barricade situations. Should there be a check or audit to ensure that the correct equipment for the relevant doors are located appropriately at prisons? ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you or your organisation has the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 23.4.2019. 1, the coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed: COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons Irwin Mitcheli solicitors (acting for the family) , BLM solicitors (acting for Care UK) and the Government Legal Service (your solicitors). have also sent it to the Prisons and Probation Ombudsman; Thompsons solicitors (acting for the Prison Officers Association) and the Independent Monitoring Board for HMP Featherstone who may find it useful or of interest: am also under a duty to send the Chief Coroner a copy of your response 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_ 26 February 2019 Andrew Haigh HM Senior Coroner for Staffordshire (South) Coroner's Office No 1 Staffordshire Place Stafford ST16 2LP Tel No: 01785 276127 sscor@staffordshire gov uk days