Michael Smith
PFD Report
Partially Responded
Ref: 2022-0417Deceased
Coroner's Concerns (AI summary)
Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable prisoner. A delay in emergency response due to staffing shortages also put his life at risk.
View full coroner's concerns
Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock. On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination. On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log, albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU, the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michale`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts
, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged led him to SACU). is a highly potent which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the (which was never diagnosed), contributed to the Michael`s death. From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route). The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future. In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things: “There is clear management oversight of the SACU”. This is not what the evidence in the instance case showed. Rather, what it made clear was that:
1) the SACU staff log plus CCTV further demonstrated that HMAC Thompson`s point to you that “officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing;
2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager);
3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing. You also stated: “I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”. This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is compromised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased.
, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged led him to SACU). is a highly potent which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the (which was never diagnosed), contributed to the Michael`s death. From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route). The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future. In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things: “There is clear management oversight of the SACU”. This is not what the evidence in the instance case showed. Rather, what it made clear was that:
1) the SACU staff log plus CCTV further demonstrated that HMAC Thompson`s point to you that “officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing;
2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager);
3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing. You also stated: “I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”. This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is compromised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased.
Responses
Action Taken
HMP Durham SACU staffing levels are above national benchmarking, overseen by a dedicated Custodial Manager. A full-time nurse is based within the SACU to provide more flexible healthcare input. HMP Durham will review its contingency plans to incorporate learning from this incident, to allow for appropriate deployment of staff should other incidents occur at the same time. (AI summary)
HMP Durham SACU staffing levels are above national benchmarking, overseen by a dedicated Custodial Manager. A full-time nurse is based within the SACU to provide more flexible healthcare input. HMP Durham will review its contingency plans to incorporate learning from this incident, to allow for appropriate deployment of staff should other incidents occur at the same time. (AI summary)
View full response
Dear Mr Oliver
Thank you for your Regulation 28 report of 10 November 2022, following the recent inquest into the death of Michael Smith at HMP Durham on 13 July 2020.
I know that you will share a copy of this response with Mr Smith’s family and I would like to first express my condolences for their loss. Each death in custody is a tragedy and the safety of those in our care is my absolute priority.
You express concern that previous actions implemented to improve the management of the Separation and Care Unit (SACU) had not had the desired effect and that staffing levels at HMP Durham needed to be increased.
I note that you have referred to a Regulation 28 response relating to an earlier death at HMP Durham. I would like to clarify that this response was sent after Mr Smith’s death, which means the additional resources that were created by the Governor would not have been implemented prior to the death of Mr Smith. However, I can assure you these additional measures do remain in place at the present time which means that the staffing levels within the SACU at Durham are currently above those required by national benchmarking, the tool by which staffing levels are measured. I would also reiterate that the day-to-day running of the unit is overseen by a dedicated Custodial Manager (CM), responsible for the allocation of tasks and performance management of the officers working there. The CM reports to and is supported by the Head of Residence and Safety (a Governor grade) who forms part of the Governor’s Senior Management Team.
The running of the SACU is further subject to daily checks undertaken by the Orderly Officer and Duty Governor, and the Governor undertakes a weekly in-charge check. Since Mr Smith’s death a new segregation weekly booklet has been introduced which amalgamates all previous segregation recording sheets together in one place. Each prisoner has their own booklet, which means an individual’s records are more readily accessible to staff. The booklet also contains a section to record any comments regarding significant interactions to ensure full records are maintained.
It may also be helpful for me to explain that where prisoners are subject to a three person unlock and staff are not readily available to facilitate this, then additional staff can be drawn from across the prison to assist. I acknowledge that that this did not happen when Mr Smith required a medical assessment and accept staff did not take the necessary actions to ensure Mr Smith could be seen by a medical practitioner. However, the Governor is confident that where this situation arises in the future the resources are in place to respond effectively. A SACU pilot, which is looking at both operational processes within the SACU and the health support provided, is due to conclude in June 2023. This will assist in developing a new workforce model to support the delivery of a safe, integrated holistic approach to the care and management of those residing and working in segregation units. As result of some early evaluations, a full time nurse is now based within the SACU, which has meant there can be a more flexible approach regarding healthcare input, including the arrangements for medical assessments.
You rightly point out that during patrol/night state, when prisoners would be locked behind their door, one officer is allocated to the SACU. However where an emergency response is required staff must undertake a dynamic risk assessment before entering a cell alone. This is the position throughout the prison during this time and would be the practice whether the person is subject to a three person unlock or not, although that information is likely to form part of the risk assessment. I do note that the decision not to enter the cell alone was not criticised and the correct procedure was followed. As you will be aware there was an unusual combination of circumstances ongoing within other parts of the prison at the time which meant the arrival of assistance was slightly delayed. Unfortunately we must accept that there will be occasions where staff may have to deal with several incidents at once and that these may be taking place in other areas of the prison. We also know that at the time of Mr Smith’s death, resources were being affected due to Durham being an Covid outbreak site. However, HMP Durham will review its contingency plans to incorporate the learning from this incident so that prompts are given to those responsible for managing protracted events to consider regime levels and available resources across the prison, to allow for the appropriate deployment of staff should other incidents occur at the same time.
Thank you again for bringing these matters of concern to my attention and I hope this provides you with the reassurances that you seek.
Thank you for your Regulation 28 report of 10 November 2022, following the recent inquest into the death of Michael Smith at HMP Durham on 13 July 2020.
I know that you will share a copy of this response with Mr Smith’s family and I would like to first express my condolences for their loss. Each death in custody is a tragedy and the safety of those in our care is my absolute priority.
You express concern that previous actions implemented to improve the management of the Separation and Care Unit (SACU) had not had the desired effect and that staffing levels at HMP Durham needed to be increased.
I note that you have referred to a Regulation 28 response relating to an earlier death at HMP Durham. I would like to clarify that this response was sent after Mr Smith’s death, which means the additional resources that were created by the Governor would not have been implemented prior to the death of Mr Smith. However, I can assure you these additional measures do remain in place at the present time which means that the staffing levels within the SACU at Durham are currently above those required by national benchmarking, the tool by which staffing levels are measured. I would also reiterate that the day-to-day running of the unit is overseen by a dedicated Custodial Manager (CM), responsible for the allocation of tasks and performance management of the officers working there. The CM reports to and is supported by the Head of Residence and Safety (a Governor grade) who forms part of the Governor’s Senior Management Team.
The running of the SACU is further subject to daily checks undertaken by the Orderly Officer and Duty Governor, and the Governor undertakes a weekly in-charge check. Since Mr Smith’s death a new segregation weekly booklet has been introduced which amalgamates all previous segregation recording sheets together in one place. Each prisoner has their own booklet, which means an individual’s records are more readily accessible to staff. The booklet also contains a section to record any comments regarding significant interactions to ensure full records are maintained.
It may also be helpful for me to explain that where prisoners are subject to a three person unlock and staff are not readily available to facilitate this, then additional staff can be drawn from across the prison to assist. I acknowledge that that this did not happen when Mr Smith required a medical assessment and accept staff did not take the necessary actions to ensure Mr Smith could be seen by a medical practitioner. However, the Governor is confident that where this situation arises in the future the resources are in place to respond effectively. A SACU pilot, which is looking at both operational processes within the SACU and the health support provided, is due to conclude in June 2023. This will assist in developing a new workforce model to support the delivery of a safe, integrated holistic approach to the care and management of those residing and working in segregation units. As result of some early evaluations, a full time nurse is now based within the SACU, which has meant there can be a more flexible approach regarding healthcare input, including the arrangements for medical assessments.
You rightly point out that during patrol/night state, when prisoners would be locked behind their door, one officer is allocated to the SACU. However where an emergency response is required staff must undertake a dynamic risk assessment before entering a cell alone. This is the position throughout the prison during this time and would be the practice whether the person is subject to a three person unlock or not, although that information is likely to form part of the risk assessment. I do note that the decision not to enter the cell alone was not criticised and the correct procedure was followed. As you will be aware there was an unusual combination of circumstances ongoing within other parts of the prison at the time which meant the arrival of assistance was slightly delayed. Unfortunately we must accept that there will be occasions where staff may have to deal with several incidents at once and that these may be taking place in other areas of the prison. We also know that at the time of Mr Smith’s death, resources were being affected due to Durham being an Covid outbreak site. However, HMP Durham will review its contingency plans to incorporate the learning from this incident so that prompts are given to those responsible for managing protracted events to consider regime levels and available resources across the prison, to allow for the appropriate deployment of staff should other incidents occur at the same time.
Thank you again for bringing these matters of concern to my attention and I hope this provides you with the reassurances that you seek.
Sent To
- Ministry of Justice
- HM Prison and Probation Service
Response Status
Linked responses
1 of 2
56-Day Deadline
1 Mar 2023
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 23 July 2020 I commenced an investigation into the death of Michael Raymond SMITH aged 31. The investigation concluded at the end of the inquest on 09 November 2022. The conclusion of the inquest was: Misadventure. And the jury added this narrative to that conclusion: A) The fact that the scanner revealed he was plugged with drugs; B) The manner in which control and restraints, and the strip search were conducted, and a failure to de-escalate; C) The absence of any mental health assessment during Michael’s arrival in reception and being discovered suspended in his cell; D) The absence of a medical assessment during Michael’s arrival in reception and being discovered in reception; and E) Michael’s use of drugs, during his time on SACU The above were all contributions that were more than minimal, negligible or trivial and probably contributed to Michael’s death. Each presented and opportunity to do something, or not do something, that would have probably prevented Michael’s death.
Circumstances of the Death
Michael entered HMP Durham on 10 July 2020. Body scan revealed he was plugged with packages. He was transferred to SACU. There was control and restraint incidents on the way an on arrival, where he was strip searched. He was placed and remained on 3 man unlock for his entire time there. At 17.45 on 11 July he was discovered self-suspended. Paramedics achieved the return of spontaneous circulation, but he died at University Hospital North Durham on 13 July 2020. The medical cause of death was:
1)a) Hypoxic brain injury b) Cardiorespiratory arrest c) Hanging Toxicology on hospital admission bloods showed toxic levels
CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock. On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination. On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log, albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU, the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michale`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts
, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged led him to SACU). is a highly potent which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the (which was never diagnosed), contributed to the Michael`s death. From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route). The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future. In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things: “There is clear management oversight of the SACU”. This is not what the evidence in the instance case showed. Rather, what it made clear was that:
1) the SACU staff log plus CCTV further demonstrated that HMAC Thompson`s point to you that “officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing;
2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager);
3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing. You also stated: “I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”. This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is compromised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased.
1)a) Hypoxic brain injury b) Cardiorespiratory arrest c) Hanging Toxicology on hospital admission bloods showed toxic levels
CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock. On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination. On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log, albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU, the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michale`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts
, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged led him to SACU). is a highly potent which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the (which was never diagnosed), contributed to the Michael`s death. From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route). The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future. In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things: “There is clear management oversight of the SACU”. This is not what the evidence in the instance case showed. Rather, what it made clear was that:
1) the SACU staff log plus CCTV further demonstrated that HMAC Thompson`s point to you that “officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing;
2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager);
3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing. You also stated: “I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”. This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is compromised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.