Ricardo Holgate
PFD Report
Partially Responded
Ref: 2019-0012
1 of 3 responded · Over 2 years old
Sent To
Response Status
Responses
1 of 3
56-Day Deadline
8 Mar 2019
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
1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area.
2. Much progress has been made as a result of the appointment of the Governing Governor Paul Newton. His appointment was for 6 months. He advised at the inquest that there is much more work to do and extension of his appointment would allow further work to be undertaken to reduce the use and supply of illicit substances in the prison and to keep inmates safe.
2. Much progress has been made as a result of the appointment of the Governing Governor Paul Newton. His appointment was for 6 months. He advised at the inquest that there is much more work to do and extension of his appointment would allow further work to be undertaken to reduce the use and supply of illicit substances in the prison and to keep inmates safe.
Responses
Response received
View full response
Dear Ms Hunt
Inquest touching upon the death of Mr Ricardo Wayne Holgate
Thank you for the Regulation 28 Report dated 11 January 2019 ('the Report') addressed to G4S, HM Prison and Probation Service and the Rt Hon David Gauke MP.
Your report was written concerning the unfortunate death of Mr Ricardo Wayne Holgate who died at HMP Birmingham on 26 March 2018. This response is sent on behalf of G4S Care and Justice Services (UK) Ltd ('G4S').
The Report raised two concerns:
(1) The New Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area.
HM Senior Coroner will be aware that at present, HMP Birmingham is being managed by HMPPS, Mr Paul Newton being the current governing Governor. Any decisions in terms of actions to be taken/equipment to be purchased and installed etc. at HMP Birmingham is not therefore currently within the remit of G4S. However, G4S does agree with Mr Newton that HMP Birmingham would benefit from CCTV and airport style scanners.
It is G4S's understanding that Mr Newton submitted to HMPPS a case for funding in respect of the cost of purchase and installation of CCTV and that this has been approved. The CCTV will therefore be installed at HMP Birmingham in due course.
Regarding the purchase and installation of airport-style scanners, it is understood that discussions between Mr Newton and HMPPS are ongoing.
(2) Much progress has been made as a result of the appointment of the Governing Governor Paul Newton. His appointment was for 6 months. He advised at the Inquest that there is much more work to do and extension of his appointment would allow further work to be undertaken to reduce the use and supply of illicit substances in the prison and to keep inmates safe.
Governor Newton's appointment is a matter between Mr Newton and HMPPS. However, we can advise that Mr Newton's appointment has been extended to allow him to continue with the improvements. We understand his appointment will be reviewed in the Summer of 2019.
I hope this provides you with assurance that the matters of concern that you have identified are being fully addressed.
Inquest touching upon the death of Mr Ricardo Wayne Holgate
Thank you for the Regulation 28 Report dated 11 January 2019 ('the Report') addressed to G4S, HM Prison and Probation Service and the Rt Hon David Gauke MP.
Your report was written concerning the unfortunate death of Mr Ricardo Wayne Holgate who died at HMP Birmingham on 26 March 2018. This response is sent on behalf of G4S Care and Justice Services (UK) Ltd ('G4S').
The Report raised two concerns:
(1) The New Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area.
HM Senior Coroner will be aware that at present, HMP Birmingham is being managed by HMPPS, Mr Paul Newton being the current governing Governor. Any decisions in terms of actions to be taken/equipment to be purchased and installed etc. at HMP Birmingham is not therefore currently within the remit of G4S. However, G4S does agree with Mr Newton that HMP Birmingham would benefit from CCTV and airport style scanners.
It is G4S's understanding that Mr Newton submitted to HMPPS a case for funding in respect of the cost of purchase and installation of CCTV and that this has been approved. The CCTV will therefore be installed at HMP Birmingham in due course.
Regarding the purchase and installation of airport-style scanners, it is understood that discussions between Mr Newton and HMPPS are ongoing.
(2) Much progress has been made as a result of the appointment of the Governing Governor Paul Newton. His appointment was for 6 months. He advised at the Inquest that there is much more work to do and extension of his appointment would allow further work to be undertaken to reduce the use and supply of illicit substances in the prison and to keep inmates safe.
Governor Newton's appointment is a matter between Mr Newton and HMPPS. However, we can advise that Mr Newton's appointment has been extended to allow him to continue with the improvements. We understand his appointment will be reviewed in the Summer of 2019.
I hope this provides you with assurance that the matters of concern that you have identified are being fully addressed.
Report Sections
Investigation and Inquest
On 06/04/2018 I commenced an investigation into the death of Ricardo Wayne Holgate. The investigation concluded at the end of an inquest on 10th January 2019. The conclusion of the jury at the inquest was:
At the time of Ricky’s death in March 2018, there was a significant issue with the supply and use of illicit substances within Birmingham prison. There was a failure to adequately control the supply and use of illicit substances within the prison.
There was an insufficient ratio of staff to prisoners. The staff were inadequately trained and insufficiently experienced in dealing with the use and effects of illicit substances.
There was a failure to rigorously implement the zero tolerance policy on the dealing and use of illicit substances in the prison. In the absence of a formal procedure about how to manage prisoners observed to be under the influence, staff made their own judgment about the response to an individual’s use of illicit substances. Management of symptoms and formal reporting of individual use of illicit substances was inconsistent.
The staff response to Ricky’s use of illicit substances on 25th March was in line with the accepted processes at the time but did not comply with the zero tolerance policy.
At the time of Ricky’s death in March 2018, there was a significant issue with the supply and use of illicit substances within Birmingham prison. There was a failure to adequately control the supply and use of illicit substances within the prison.
There was an insufficient ratio of staff to prisoners. The staff were inadequately trained and insufficiently experienced in dealing with the use and effects of illicit substances.
There was a failure to rigorously implement the zero tolerance policy on the dealing and use of illicit substances in the prison. In the absence of a formal procedure about how to manage prisoners observed to be under the influence, staff made their own judgment about the response to an individual’s use of illicit substances. Management of symptoms and formal reporting of individual use of illicit substances was inconsistent.
The staff response to Ricky’s use of illicit substances on 25th March was in line with the accepted processes at the time but did not comply with the zero tolerance policy.
Circumstances of the Death
The jury recorded the following:
Ricky was transferred to Birmingham Prison on 7th March 2018 and placed on K wing.
At 9:30am on 25th March 2018 a prisoner on K wing was observed under the influence of an illicit substance and returned to his cell.
Between 3 and 4pm, during association, Ricky was observed by a prison Officer with red eyes, walking slowly but talking and was thought to be under the influence of an illicit substance. This was not a cause for staff concern.
At 16:45, healthcare staff were called to attend a number of prisoners on K wing who were under the influence of suspected psychoactive substances. A verbal report about Ricky was made to them by prison staff.
By 5pm, Ricky was locked in his cell having been spoken to, while sat on the toilet, by a prison officer. Roll calls of the wing completed by 09:15pm and in the morning of 26th March by 6am.
On the morning of 26th March, during routine unlocking 0f cell K1 -27 Ricky was discovered by a prison officer lying face down on his bunk with no pulse. He was declared dead at 7.54. The post mortem confirmed his death was due to coronary artery thrombosis contributed to by his use of synthetic cannabinoids and prescription codeine.
Following a post mortem the medical cause of death was determined to be: 1a. CORONARY ARTERY THROMBOSIS 1b. CORONARY ARTERY ATHEROSCLEROSIS
2. COMBINED EFFECTS OF SYNTHETIC CANNABINOID AND CODINE
Ricky was transferred to Birmingham Prison on 7th March 2018 and placed on K wing.
At 9:30am on 25th March 2018 a prisoner on K wing was observed under the influence of an illicit substance and returned to his cell.
Between 3 and 4pm, during association, Ricky was observed by a prison Officer with red eyes, walking slowly but talking and was thought to be under the influence of an illicit substance. This was not a cause for staff concern.
At 16:45, healthcare staff were called to attend a number of prisoners on K wing who were under the influence of suspected psychoactive substances. A verbal report about Ricky was made to them by prison staff.
By 5pm, Ricky was locked in his cell having been spoken to, while sat on the toilet, by a prison officer. Roll calls of the wing completed by 09:15pm and in the morning of 26th March by 6am.
On the morning of 26th March, during routine unlocking 0f cell K1 -27 Ricky was discovered by a prison officer lying face down on his bunk with no pulse. He was declared dead at 7.54. The post mortem confirmed his death was due to coronary artery thrombosis contributed to by his use of synthetic cannabinoids and prescription codeine.
Following a post mortem the medical cause of death was determined to be: 1a. CORONARY ARTERY THROMBOSIS 1b. CORONARY ARTERY ATHEROSCLEROSIS
2. COMBINED EFFECTS OF SYNTHETIC CANNABINOID AND CODINE
Copies Sent To
Birmingham Community Healthcare NHS Trust
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.