Nicholas Rose
PFD Report
All Responded
Ref: 2022-0106
All 1 response received
· Deadline: 21 Jun 2022
Coroner's Concerns (AI summary)
Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true welfare, potentially missing signs of distress or incapacitation.
View full coroner's concerns
1. During the inquest evidence was heard that:
i. When Mr Rose's cell was unlocked on the morning of 19th May 2019 at approximately 8.45 am and the welfare check was conducted, the evidence given was that Mr Rose responded with a "grunt". Evidence was also heard regarding the "Notice to Prison Officers" number 191/2017, issued on 30th August 2017, which requires that a verbal response is elicited from a prisoner during a welfare check. The corresponding "Notice to Prisoners" number 083/2017, issued on the same day, instructs prisoners that they "must give a verbal response such as Good Morning/Afternoon, Hello".
ii. Evidence was heard that a "grunt" in response to a welfare check is considered acceptable, and fulfils the requirement for a "verbal response".
2. I have concerns with regard to the following :
i. I am concerned that accepting a "grunt" as a verbal response to a welfare check does not fulfil the requirement as set out in the Notice to Prison Officers mentioned above. Such a response gives very limited information upon which a prison officer can assess a prisoner's welfare. Accepting such a response potentially loses sight of the purpose of a welfare check, which must be to check that the prisoner is alive, immediately safe and well; that is, that they are conscious, breathing, not in a state of distress, not in a state of intoxication and that there are not any other factors that might require immediate intervention to prevent harm. A verbal response to a welfare check allows a prison officer to assess if a prisoner has responded in an appropriate manner, giving an indication as to whether the prisoner retains the cognitive function to provide an appropriate response. A "grunt" does not allow such an assessment. Therefore, I have a concern that future deaths could occur if accepting such a response remains the accepted practice.
i. When Mr Rose's cell was unlocked on the morning of 19th May 2019 at approximately 8.45 am and the welfare check was conducted, the evidence given was that Mr Rose responded with a "grunt". Evidence was also heard regarding the "Notice to Prison Officers" number 191/2017, issued on 30th August 2017, which requires that a verbal response is elicited from a prisoner during a welfare check. The corresponding "Notice to Prisoners" number 083/2017, issued on the same day, instructs prisoners that they "must give a verbal response such as Good Morning/Afternoon, Hello".
ii. Evidence was heard that a "grunt" in response to a welfare check is considered acceptable, and fulfils the requirement for a "verbal response".
2. I have concerns with regard to the following :
i. I am concerned that accepting a "grunt" as a verbal response to a welfare check does not fulfil the requirement as set out in the Notice to Prison Officers mentioned above. Such a response gives very limited information upon which a prison officer can assess a prisoner's welfare. Accepting such a response potentially loses sight of the purpose of a welfare check, which must be to check that the prisoner is alive, immediately safe and well; that is, that they are conscious, breathing, not in a state of distress, not in a state of intoxication and that there are not any other factors that might require immediate intervention to prevent harm. A verbal response to a welfare check allows a prison officer to assess if a prisoner has responded in an appropriate manner, giving an indication as to whether the prisoner retains the cognitive function to provide an appropriate response. A "grunt" does not allow such an assessment. Therefore, I have a concern that future deaths could occur if accepting such a response remains the accepted practice.
Responses
Action Taken
HMP Guys Marsh has republished notices to staff and prisoners regarding the requirement for verbal responses during welfare checks, with compliance checks by wing Custodial Managers, and has introduced toolbox talks for Prison Officers, including training on welfare checks. (AI summary)
HMP Guys Marsh has republished notices to staff and prisoners regarding the requirement for verbal responses during welfare checks, with compliance checks by wing Custodial Managers, and has introduced toolbox talks for Prison Officers, including training on welfare checks. (AI summary)
View full response
Dear Mr Allen,
Thank you for your Regulation 28 report of 7 April 2022, received on 26 April, addressed to the Governor of HMP Guys Marsh following the inquest into the death of Nicholas Rose on 19 May 2019. I am responding on behalf of HMPPS as Director General of Prisons.
I know that you will share a copy of this response with the family of Mr Rose and I would 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.
Following evidence heard at the inquest you have raised a concern in relation to the level of response required from a prisoner during the welfare checks conducted when prisoners are unlocked to assure staff that there are no issues of concern.
Residential staff play a key role in keeping prisoners safe and effective welfare checks can identify signs of distress, incidents where staff assistance may be required, and medical emergencies. Prison Service Instruction (PSI 75/2011 Residential Services) sets out the requirement on all establishments to have in place appropriate arrangements and clearly understood systems for staff to assure themselves of the wellbeing of prisoners through welfare checks.
I understand that evidence was given at the inquest that HMP Guys Marsh’s local arrangement is that staff must receive a verbal response from prisoners during welfare checks and at unlock, and that notices to staff and prisoners have been issued setting out this requirement. I have received assurance from the Governing Governor that further notices to staff and prisoners were published in May 2022, following the inquest, to serve as a reminder of the expectations during welfare checks that a verbal response must be obtained, not a grunt, and that if a verbal response is not obtained then staff must access the cell to check on the welfare of the prisoner. Notices to staff and prisoners will now be re- published regularly and compliance checks are carried out by wing Custodial Managers (CMs) who observe officers unlocking prisoners to ensure that welfare checks are being carried out correctly, and this is recorded each day in wing diaries. A review of the assurance checks is carried out on a monthly basis by the Head of Residence and any
member of staff who fails to meet the required standard is challenged through the HMPSS performance management process.
HMP Guys Marsh has introduced toolbox talks for Prison Officers (short subject-specific training sessions) and this has included training with regard to welfare checks. The last session was completed in March 2022 as part of a safety awareness month held for all staff. Welfare checks will continue to feature as part of all relevant safety based training events.
Prison officers undertaking initial training (currently known as New Officer Apprentices) are trained to conduct checks and the training emphasises the requirement for officers to confirm the safety and welfare of prisoners during roll checks, unlocks, and welfare checks.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised.
Thank you for your Regulation 28 report of 7 April 2022, received on 26 April, addressed to the Governor of HMP Guys Marsh following the inquest into the death of Nicholas Rose on 19 May 2019. I am responding on behalf of HMPPS as Director General of Prisons.
I know that you will share a copy of this response with the family of Mr Rose and I would 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.
Following evidence heard at the inquest you have raised a concern in relation to the level of response required from a prisoner during the welfare checks conducted when prisoners are unlocked to assure staff that there are no issues of concern.
Residential staff play a key role in keeping prisoners safe and effective welfare checks can identify signs of distress, incidents where staff assistance may be required, and medical emergencies. Prison Service Instruction (PSI 75/2011 Residential Services) sets out the requirement on all establishments to have in place appropriate arrangements and clearly understood systems for staff to assure themselves of the wellbeing of prisoners through welfare checks.
I understand that evidence was given at the inquest that HMP Guys Marsh’s local arrangement is that staff must receive a verbal response from prisoners during welfare checks and at unlock, and that notices to staff and prisoners have been issued setting out this requirement. I have received assurance from the Governing Governor that further notices to staff and prisoners were published in May 2022, following the inquest, to serve as a reminder of the expectations during welfare checks that a verbal response must be obtained, not a grunt, and that if a verbal response is not obtained then staff must access the cell to check on the welfare of the prisoner. Notices to staff and prisoners will now be re- published regularly and compliance checks are carried out by wing Custodial Managers (CMs) who observe officers unlocking prisoners to ensure that welfare checks are being carried out correctly, and this is recorded each day in wing diaries. A review of the assurance checks is carried out on a monthly basis by the Head of Residence and any
member of staff who fails to meet the required standard is challenged through the HMPSS performance management process.
HMP Guys Marsh has introduced toolbox talks for Prison Officers (short subject-specific training sessions) and this has included training with regard to welfare checks. The last session was completed in March 2022 as part of a safety awareness month held for all staff. Welfare checks will continue to feature as part of all relevant safety based training events.
Prison officers undertaking initial training (currently known as New Officer Apprentices) are trained to conduct checks and the training emphasises the requirement for officers to confirm the safety and welfare of prisoners during roll checks, unlocks, and welfare checks.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised.
Sent To
- HMP Guys Marsh Prison
Response Status
Linked responses
1 of 1
56-Day Deadline
21 Jun 2022
All responses received
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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 the 28th May 2019, an investigation was commenced into the death of Nicholas Tom Rose, born on the 18th June 1981. The investigation concluded at the end of the Inquest on the 24th March 2022. The Medical Cause of Death was: la Airway Obstruction lb Aspiration of Gastric Content le SF-MDMB-PINACA ("Spice'') Intoxication The conclusion of the Inquest recorded by the jury was that Nicholas Tom Rose died as a consequence of misadventure.
Circumstances of the Death
Nicholas Tom Rose was a serving prisoner at HMP Guys Marsh at the time of his 19th death. He was a resident on Jubilee Wing. On Sunday May 2019 at approximately 8.45 am at the morning "unlock", a welfare check was conducted. Mr Rose was in in bed in his cell at this time. At 12.15pm, when the roll call was conducted, Mr Rose was found deceased in his cell on Jubilee Wing. Mr Rose was still in bed. A post mortem examination, including toxicological analysis of samples of fluid, revealed that Mr Rose had consumed "Spice" prior to his death, which led to the aspiration of gastric content and airway obstruction.
Copies Sent To
Government Legal Department on behalf of the Ministry of Justice
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.