Dear Ms Bower, Inquest into the death of Nigel Saunders Thank you for your Prevention of Future Deaths report received on 3 August 2022. You will recall that Mr Saunders sadly passed away on 18 November 2018. I am responding to matters of concern that you have raised relating to HMP Lowdham Grange ('the Prison') which is operated by Serco Limited, where Mr Saunders was detained at the time of his death. I am aware that you will share a copy of this response with Mr Saunders' family, and I would like to express my sincere condolences for their loss. Every death in custody is a tragedy, and the safety of those detained by the Prison is my absolute priority. I am grateful to you for bringing the following matters of concern to my attention: (1) The Prison failed to comply with its obligations pursuant to National Prison policy to retain and preserve evidence likely to assist all agencies to learnfrom deaths in custody; and (2) The local system in place for the retention and preservation of material likely ta be relevant to the circumstances ofdeath is not as robust as it ought to be. The Prison is aware of its obligation to retain and preserve evidence following a death in custody ("DIC") as set out in National Prison Policy, PSI 6412011 Management of Offenders at Risk of Harm to self and others (Safer Custody) ('the PSI) and takes its responsibilities in this regard very seriously. Policy at time of Mr Saunders' Death Document retention provisions following DICs were in place at the Prison at the time of Mr Saunders' death, pursuant to the National Prison Policy, specifically the PSI, and were implemented at the Prison in the form of the Serco Divisional Operating Procedure ­ Investigation and Management of Death in Custody Incidents ("DSOP'?. The DSOP was, and still is, applicable nationally to all deaths that occurred in Serco's custody. The DSOP included: ­
• A DIC checklist which set out all of the documents that were required to be retained and available to the Police, the PPO and HM Coroner when required.
• a Death in Custody Response Plan However, it is acknowledged that there were some short comings in the retention and production of some documentation in relation to Mr Saunders' death. Justice and lmmlgrallon, adivision ofSe.-co Limited. Acompeny reglslsnld In England and WalesNO. 242248. Reglstellld Office: Seroo Holl98, Ill Barlloy Ytbod Business PaJ1<, Bal1tey Way, Hook, ~re RG27 gu-,: Unitad Kingdom.

Policy Updates Prior to Inquest In January 2021 the DSOP was updated. The DSOP is reviewed and updated regularly as appropriate and in any event every two years. Policy Changes Post Inquest Following this inquest, the DSOP, including tne DIC checKllst nas been reviewed further and an updated version is to be rolled out to the Eng:ish Serco prison estate by the end of October 2022. The updated version of the DSOP will include a statement that the DIC Checklist is not an exhaustive list, and the Prison should retain any other document that it considers could be of relevance. The updated DSOP will be rolled out across the prison estate and guidance will be given to all staff responsible for collating relevant documentation following a death in custody. I understand that a copy of the DIC checklist that was in place at the time of Mr Saunders death and a copy of the DIC checklist, as amended in January 2021 were provided to you during the course of the Inquest. The most recent version of the checklist is currently being finalised prior to its roll out at the end of October 2022. Documents of Specific Concern During the Inquest I became aware of specific concerns you had in respect of disclosure, and I would like to offer the following reassurances, by way of example: ACCT Tick Sheets At the time of Mr Saunders' death, it was standard practice for observation 'tick sheets' to be completed for those prisoners subject to an ACCT. Despite the requirement to retain the tick sheets in accordance with the DIC Checklist in place at the time, it was accepted during evidence that the tick sheets in relation to Mr Saunders could not be located. Following the introduction of Version 6 of 'ACCT - Policy Guidance - Annex', which was rolled out nationally in 2021 the use of these 'tick sheets' has been discontinued across all prisons in the UK. All records relating to the ACCT process are now contained within the ACCT book itself. Oscar Journal You may recall that the Oscar is the senior member of prison staff, who has overall operational responsibility for the Prison e.g., incident management etc. The Oscar Journal ('the Journal'), is a large leather-bound folder where relevant material from each shift was recorded by the Oscar, for example details of anyone who is self-harming and incidents of violence to aid information sharing. Over the years the Journal has been replaced by incident reports, which are completed and then reported to and discussed by the Director and the Senior Management Team on a daily basis. It is accepted that Journal entries may have contained relevant information following a DIC and consequently should have been included on the DIC checklist to ensure their preservation following a death. The Journal is now listed in the checklist, to ensure it is produced in Serco prisons that use an Oscars journal.

Dear

Prevention of Future Deaths Report

Thank you for your response to the Prevention of Future Deaths report that I issued following the inquest touching the death of Nigel John Saunders.

I am so pleased to read of the broad range of measures you have put in place to address my concerns.

I understand the improvements you have made to the Prison’s investigation of deaths in custody processes are now being rolled out across the SERCO English prison estate. This will assist with learning from deaths in custody, with the overarching objective of seeking to reduce the number of preventable deaths that occur in prisons every year.

Two further matters occur to me on considering your helpful response.

Firstly, the Chief Coroner has, very recently, issued Coroners across England and Wales with new guidance in relation to Disclosure. At paragraph 4, the Chief Coroner suggests an undertaking be lodged by Interested Persons declaring that due diligence has been exercised in relation to the retention and disclosure of all relevant material. Consideration might be given to aligning your processes to include an undertaking similar to that suggested by the Chief Coroner. My practise in Nottingham has been to ask that the Prison Governor and the legal representative sign and lodge with the Coroner a copy of the undertaking at the end of the disclosure process. This additional step promotes a culture of openness, transparency and accountability, values which are so important to these very sensitive investigations. I include a link to the guidance, which is accessible to the public, here: GUIDANCE No 44 DISCLOSURE final (judiciary.uk)

Secondly, it does occur to me that the improvements you have overseen on behalf of SERCO, might actually assist the non-SERCO managed prisons estate in seeking to comply with their duties, and for that reason, I am going to copy my report and your response, along with this letter, to the Minister of State for Justice, Mr Rob Butler MP, purely for information purposes. A copy shall also be shared with the family, other Interested Persons and the Chief Coroner.

There has to be a commitment across all agencies to place bereaved families at the heart of the investigation process, and to seek to extract every opportunity for learning from these tragic deaths. I am grateful for the work you have undertaken in this regard.