Robert Evans
PFD Report
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Ref: 2022-0322
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· Deadline: 15 Dec 2022
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
During the inquest the evidence revealed matters giving rise to a concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to make a report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
The first MATTERS OF CONCERN is as follows: . I am aware that Her Majesty’s Chief Inspector of Prisons 2018 inspection report in respect of HMP Swansea stated that. “there have been four self-inflicted deaths since the previous inspection, all within a week of arrival. This replicated findings at our previous inspection of Swansea” [S5]. The most current report of Her Majesty’s Chief Inspector of Prisons dated 2020 states, “There had been two self-inflicted deaths since the last inspection, the most recent in December 2019. Both had occurred soon after the prisoners arrived at the prison” [1.23]. I have heard evidence that it is well known by prison staff and recognised in national Ministry of Justice policy and in HMP Swansea Prison Policy that the very early days are a particularly high-risk time for prisoners particularly those on remand or recalled on licence. This is supported by the findings of the above inspection report.
I heard that there is a safer cell on the induction unit and in that cell the whole window unit has been replaced with plastic material that can be slid to allow prisoners to get air from the outside into the cell. I heard evidence that prisoners are not on the induction unit for a significant period but that prisoners in the induction unit are in a vulnerable time in custody as they have just arrived in prison. The second MATTERS OF CONCERN is as follows: I heard evidence from the two prison officers who appear in the HMP Swansea CCTV as mentioned above. On the evidence I have seen these witnesses were the last members of prison staff Lee spoke to before his death. At all stages into the investigation into Lee’s death (prisons and probations ombudsman and coronial) these witnesses have stated that they are unable to assist with what Lee was saying to them hours before his death. I am concerned that immediately following Lee’s death and the following day that these highly material witnesses (who were on duty) were not spoken to, did not attend a hot or cold debrief and were not asked to make a first account of events when matters were fresh in their minds. These witnesses did become known to the PPO. As a result, my investigation into Lee’s death has been significantly hampered. I am therefore concerned that lessons may not have been fully learnt from the circumstances of Lee’s death. I am concerned that if evidence relevant to a death in custody is not immediately captured and considered a situation may be created where evidence is lost which prevents general lessons from being learnt from a death in custody and that this creates a risk that other deaths will occur.
The first MATTERS OF CONCERN is as follows: . I am aware that Her Majesty’s Chief Inspector of Prisons 2018 inspection report in respect of HMP Swansea stated that. “there have been four self-inflicted deaths since the previous inspection, all within a week of arrival. This replicated findings at our previous inspection of Swansea” [S5]. The most current report of Her Majesty’s Chief Inspector of Prisons dated 2020 states, “There had been two self-inflicted deaths since the last inspection, the most recent in December 2019. Both had occurred soon after the prisoners arrived at the prison” [1.23]. I have heard evidence that it is well known by prison staff and recognised in national Ministry of Justice policy and in HMP Swansea Prison Policy that the very early days are a particularly high-risk time for prisoners particularly those on remand or recalled on licence. This is supported by the findings of the above inspection report.
I heard that there is a safer cell on the induction unit and in that cell the whole window unit has been replaced with plastic material that can be slid to allow prisoners to get air from the outside into the cell. I heard evidence that prisoners are not on the induction unit for a significant period but that prisoners in the induction unit are in a vulnerable time in custody as they have just arrived in prison. The second MATTERS OF CONCERN is as follows: I heard evidence from the two prison officers who appear in the HMP Swansea CCTV as mentioned above. On the evidence I have seen these witnesses were the last members of prison staff Lee spoke to before his death. At all stages into the investigation into Lee’s death (prisons and probations ombudsman and coronial) these witnesses have stated that they are unable to assist with what Lee was saying to them hours before his death. I am concerned that immediately following Lee’s death and the following day that these highly material witnesses (who were on duty) were not spoken to, did not attend a hot or cold debrief and were not asked to make a first account of events when matters were fresh in their minds. These witnesses did become known to the PPO. As a result, my investigation into Lee’s death has been significantly hampered. I am therefore concerned that lessons may not have been fully learnt from the circumstances of Lee’s death. I am concerned that if evidence relevant to a death in custody is not immediately captured and considered a situation may be created where evidence is lost which prevents general lessons from being learnt from a death in custody and that this creates a risk that other deaths will occur.
Responses
HM Prison and Probation Service has replaced a ventilation unit in a safer cell to reduce ligature points. They are also undertaking a national review of ligature-resistant cells and drafting a new policy framework to improve early recording of staff recollections following deaths in custody.
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Dear Ms Heaven,
Thank you for your Regulation 28 report of 20 October 2022, addressed to the Governor of HMP Swansea and myself. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.
I know that you will share a copy of this response with Mr Evan’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have expressed concerns regarding in the safer cell on the induction unit at HMP Swansea and the capturing of evidence immediately after a death in custody.
As you have described, the unit within the safer cell on the induction unit has been replaced with plastic material that can be slid to allow prisoners to gain air from the outside into the cell. This function reduces the risk of an individual utilising the bars as a ligature point and, in certain cases, those who are assessed as presenting with higher or imminent risk of suicide will be located there. Whilst replacing the in the normal cells on the induction unit at HMP Swansea with those described will mitigate the risk of individuals using
as ligature points, it would not make these cells ligature-resistant. Therefore, the suggested action will be made at a prohibitive cost as we do not consider that the change will achieve its intended outcome of mitigating all risk.
Staff recognise that prisoners may feel vulnerable during their early days in custody and HMPPS uses the Assessment, Care in Custody, Teamwork (ACCT) case management approach to support people at risk of self-harm and suicide. As part of any case review, those present will consider the prisoner’s location and whether any possessions need to be removed or returned, and this may include moving the prisoner to a ligature-resistant cell if appropriate. HMP Swansea has multiple ligature-resistant cells that are available to locate prisoners who are assessed as being at imminent risk of self-harm or suicide.
At a national level, HMPPS is undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible, including from the The review will include their build standards and how they are used to support prisoners in crisis. Our aim is to ensure that cells that are fitted with ligature-resistant features are available as an option for staff managing prisoners in crisis, and that they retain those features in full working order and do not deviate from the standard over time. At this point it is too early to say what new rules may be introduced, such as setting the frequency of maintenance, although we do recognise that cells are subject to constant wear and tear and need frequent attention to keep them up to standard.
I recognise the importance of ensuring that any evidence relating to deaths in custody is preserved, including the recollections of staff who have had recent interactions with the deceased individual. Prisons are required to have contingency plans in place that include debriefs with staff who were on the scene at the time of the incident, but these will not be the only staff to have had potentially relevant contact with the prisoner. We are currently drafting a new HMPPS Policy Framework, updating the policy for prisons to follow in the event of a death in custody, and within this will include guidance for prisons to ensure that staff who have relevant information are identified and prompted to make a record of this at an early stage. This will ensure that it is available at a later date, even if they are not required to give a police statement or interviewed by the Prisons and Probation Ombudsman (PPO) as part of their investigation.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
Thank you for your Regulation 28 report of 20 October 2022, addressed to the Governor of HMP Swansea and myself. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.
I know that you will share a copy of this response with Mr Evan’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have expressed concerns regarding in the safer cell on the induction unit at HMP Swansea and the capturing of evidence immediately after a death in custody.
As you have described, the unit within the safer cell on the induction unit has been replaced with plastic material that can be slid to allow prisoners to gain air from the outside into the cell. This function reduces the risk of an individual utilising the bars as a ligature point and, in certain cases, those who are assessed as presenting with higher or imminent risk of suicide will be located there. Whilst replacing the in the normal cells on the induction unit at HMP Swansea with those described will mitigate the risk of individuals using
as ligature points, it would not make these cells ligature-resistant. Therefore, the suggested action will be made at a prohibitive cost as we do not consider that the change will achieve its intended outcome of mitigating all risk.
Staff recognise that prisoners may feel vulnerable during their early days in custody and HMPPS uses the Assessment, Care in Custody, Teamwork (ACCT) case management approach to support people at risk of self-harm and suicide. As part of any case review, those present will consider the prisoner’s location and whether any possessions need to be removed or returned, and this may include moving the prisoner to a ligature-resistant cell if appropriate. HMP Swansea has multiple ligature-resistant cells that are available to locate prisoners who are assessed as being at imminent risk of self-harm or suicide.
At a national level, HMPPS is undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible, including from the The review will include their build standards and how they are used to support prisoners in crisis. Our aim is to ensure that cells that are fitted with ligature-resistant features are available as an option for staff managing prisoners in crisis, and that they retain those features in full working order and do not deviate from the standard over time. At this point it is too early to say what new rules may be introduced, such as setting the frequency of maintenance, although we do recognise that cells are subject to constant wear and tear and need frequent attention to keep them up to standard.
I recognise the importance of ensuring that any evidence relating to deaths in custody is preserved, including the recollections of staff who have had recent interactions with the deceased individual. Prisons are required to have contingency plans in place that include debriefs with staff who were on the scene at the time of the incident, but these will not be the only staff to have had potentially relevant contact with the prisoner. We are currently drafting a new HMPPS Policy Framework, updating the policy for prisons to follow in the event of a death in custody, and within this will include guidance for prisons to ensure that staff who have relevant information are identified and prompted to make a record of this at an early stage. This will ensure that it is available at a later date, even if they are not required to give a police statement or interviewed by the Prisons and Probation Ombudsman (PPO) as part of their investigation.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
Report Sections
Investigation and Inquest
On 14 January 2018 an investigation was commenced into the death of Robert Lee Evans, a prisoner at HMP Swansea, who was found deceased in his cell in the early hours of 14 January 2018 after having tied a ligature around his neck. He was 37 years of age at the time of his death. The investigation concluded at the end of the inquest on 13 October 2022.
The medical cause of death was: 1a pressure on neck (hanging)
The conclusion of the inquest was a narrative conclusion as follows:
Considering the information that was known to the prison about Lee, the prison probably failed to adequately assess his risk of suicide and self-harm. During the period from lock up to midnight only, there was probably not an adequate system of checks in place for Lee in light of the fact that he was undergoing alcohol detoxification and on the induction wing and in the early days prison. This probably made a more than minimal contribution to Lee's death. The prison doctor probably failed to review Lee's medical notes sufficiently. This probably made a more than minimal contribution to Lee's death. The prison doctor probably failed to prescribe Lee's antidepressant medication. This possibly made a more than minimal contribution to Lee's death. The prison doctor probably failed to prescribe Lee's detoxification medication. This probably made a more than minimal psychological contribution to Lee's death. The systems and processes in place probably contributed to the failure of the health staff reviewing all records. The prison and medical staff within the prison probably did not take all appropriate steps to safeguard Lee when he was in prison custody, for example by not opening an ACCT, and by the way prescription information was communicated to Lee. This probably made a more than minimal contribution to his death.
The medical cause of death was: 1a pressure on neck (hanging)
The conclusion of the inquest was a narrative conclusion as follows:
Considering the information that was known to the prison about Lee, the prison probably failed to adequately assess his risk of suicide and self-harm. During the period from lock up to midnight only, there was probably not an adequate system of checks in place for Lee in light of the fact that he was undergoing alcohol detoxification and on the induction wing and in the early days prison. This probably made a more than minimal contribution to Lee's death. The prison doctor probably failed to review Lee's medical notes sufficiently. This probably made a more than minimal contribution to Lee's death. The prison doctor probably failed to prescribe Lee's antidepressant medication. This possibly made a more than minimal contribution to Lee's death. The prison doctor probably failed to prescribe Lee's detoxification medication. This probably made a more than minimal psychological contribution to Lee's death. The systems and processes in place probably contributed to the failure of the health staff reviewing all records. The prison and medical staff within the prison probably did not take all appropriate steps to safeguard Lee when he was in prison custody, for example by not opening an ACCT, and by the way prescription information was communicated to Lee. This probably made a more than minimal contribution to his death.
Circumstances of the Death
The deceased was Robert Lee Evans
On Sunday 14 January 2018 (in the early hours) Lee was founded just over 24 hours after his arrival into HMP Swansea. Lee was in a cell on his own at his own request. Lee had been released on licence from HMP Swansea on 29 January 2017. When arriving in HMP Swansea Lee was undergoing detoxification from alcohol and had been given certain medication under the patient group directive both in police custody and then in prison. There were historic risk markers for suicide and self-harm on the PER from police custody and on NOEMIS – the prison system. The PER recorded anxiety and depression and that Lee had not had his anti-depressant medication for several days. Lee was not on an ACCT. There was evidence in prison medical records showing that Lee had been prescribed anti-depressant medication for depression and anxiety when in HMP Swansea on previous occasions and that on 29 January 2017 Lee was released from HMP Swansea with a month’s supply of this medication. On Saturday 13 January 2018 the prison doctor reviewed Lee’s notes but did not prescribe Lee’s anti-depressant medication and did not write up Lee’s prescription for his alcohol withdrawal medication. Lee was told that the doctor had not written up his alcohol withdrawal prescription and this made Lee anxious at the medication hatch. However, at the nurse’s discretion Lee was given his evening dose of his alcohol withdrawal medication. Shortly afterwards Lee can be seen on CCTV speaking to two prison officers in an animated way and for approximately one minute. I have been unable to establish what Lee was saying. Shortly after this interaction Lee can be seen walking in the direction of the area that houses the post box holding a piece of paper and envelope and then returning to his cell empty handed. Lee was locked in his cell at around 4.30 and was not checked until he was founded suspended by a nurse commencing the first of three nightly checks shortly after midnight. After Lee’s death a letter was found in the HMP Swansea post box written by Lee to his partner which indicated that at an earlier time Lee was fine but on the other side Lee had written “they stopped my meds goodbye I quit loved you”. It was clear from the evidence that this letter could only have been posted on the Saturday.
On Sunday 14 January 2018 (in the early hours) Lee was founded just over 24 hours after his arrival into HMP Swansea. Lee was in a cell on his own at his own request. Lee had been released on licence from HMP Swansea on 29 January 2017. When arriving in HMP Swansea Lee was undergoing detoxification from alcohol and had been given certain medication under the patient group directive both in police custody and then in prison. There were historic risk markers for suicide and self-harm on the PER from police custody and on NOEMIS – the prison system. The PER recorded anxiety and depression and that Lee had not had his anti-depressant medication for several days. Lee was not on an ACCT. There was evidence in prison medical records showing that Lee had been prescribed anti-depressant medication for depression and anxiety when in HMP Swansea on previous occasions and that on 29 January 2017 Lee was released from HMP Swansea with a month’s supply of this medication. On Saturday 13 January 2018 the prison doctor reviewed Lee’s notes but did not prescribe Lee’s anti-depressant medication and did not write up Lee’s prescription for his alcohol withdrawal medication. Lee was told that the doctor had not written up his alcohol withdrawal prescription and this made Lee anxious at the medication hatch. However, at the nurse’s discretion Lee was given his evening dose of his alcohol withdrawal medication. Shortly afterwards Lee can be seen on CCTV speaking to two prison officers in an animated way and for approximately one minute. I have been unable to establish what Lee was saying. Shortly after this interaction Lee can be seen walking in the direction of the area that houses the post box holding a piece of paper and envelope and then returning to his cell empty handed. Lee was locked in his cell at around 4.30 and was not checked until he was founded suspended by a nurse commencing the first of three nightly checks shortly after midnight. After Lee’s death a letter was found in the HMP Swansea post box written by Lee to his partner which indicated that at an earlier time Lee was fine but on the other side Lee had written “they stopped my meds goodbye I quit loved you”. It was clear from the evidence that this letter could only have been posted on the Saturday.
Inquest Conclusion
Considering the information that was known to the prison about Lee, the prison probably failed to adequately assess his risk of suicide and self-harm. During the period from lock up to midnight only, there was probably not an adequate system of checks in place for Lee in light of the fact that he was undergoing alcohol detoxification and on the induction wing and in the early days prison. This probably made a more than minimal contribution to Lee's death. The prison doctor probably failed to review Lee's medical notes sufficiently. This probably made a more than minimal contribution to Lee's death. The prison doctor probably failed to prescribe Lee's antidepressant medication. This possibly made a more than minimal contribution to Lee's death. The prison doctor probably failed to prescribe Lee's detoxification medication. This probably made a more than minimal psychological contribution to Lee's death. The systems and processes in place probably contributed to the failure of the health staff reviewing all records. The prison and medical staff within the prison probably did not take all appropriate steps to safeguard Lee when he was in prison custody, for example by not opening an ACCT, and by the way prescription information was communicated to Lee. This probably made a more than minimal contribution to his death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.