Carl Walters
PFD Report
All Responded
Ref: 2021-0256
All 1 response received
· Deadline: 22 Sep 2021
Coroner's Concerns (AI summary)
The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and preventative measures overlooked.
View full coroner's concerns
The failure to preserve key evidence meant that the inquest could not be as full as it would otherwise have been. If key evidence is not preserved there is an ongoing risk that dangerous conditions or circumstances go undiscovered raising the prospect that appropriate steps to avoid a similar tragedy are overlooked.
Responses
Action Taken
HMP Exeter created a local operating policy for deaths in custody, including a list of essential documents to retain (cell bell records, CCTV, body-worn video). A new CCTV system has been installed, and all deaths in custody are subject to a quick-time learning review by the Head of Safety and Regional Groups Safety Lead. (AI summary)
HMP Exeter created a local operating policy for deaths in custody, including a list of essential documents to retain (cell bell records, CCTV, body-worn video). A new CCTV system has been installed, and all deaths in custody are subject to a quick-time learning review by the Head of Safety and Regional Groups Safety Lead. (AI summary)
View full response
Dear Mr Rheinberg,
Thank you for your Regulation 28 report of 28 July 2021 following the inquest into the death of Carl Lee Walters at HMP Exeter on 30 March 2019. I am grateful to you for granting an extension to the statutory deadline for my response.
I know that you will share a copy of this response with the family of Mr Walters 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 the inquest, you have raised a concern in relation to the failure to preserve key evidence which could mean that dangerous conditions or circumstances go undiscovered. You point out that this raises the prospect that appropriate steps to avoid a similar tragedy are overlooked. I am grateful to you for bringing your concern to my attention.
As a consequence of Mr Walters’ death and the discovery of HMP Exeter’s deficiencies with regard to the preservation of key evidence, new measures and processes have been put in place to prevent similar circumstances in the future. In particular, HMP Exeter have created a local operating policy for deaths in custody, which contains a list of essential documents that must be retained and the required actions. Included within the list is the collation of relevant cell bell records, CCTV and Body Worn Video Camera footage of any incident. Also, since Mr Walters’ death a new CCTV system has been installed which provides a more reliable source of footage.
In addition to the above, all deaths in custody at HMP Exeter are subject to a quick time learning review conducted by the Head of Safety and Regional Groups Safety Lead. This occurs within 72 hours of any apparent self-inflicted death taking place and as a result requires all pertinent information, including CCTV footage and cell bell records, to be made available and reviewed.
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 28 July 2021 following the inquest into the death of Carl Lee Walters at HMP Exeter on 30 March 2019. I am grateful to you for granting an extension to the statutory deadline for my response.
I know that you will share a copy of this response with the family of Mr Walters 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 the inquest, you have raised a concern in relation to the failure to preserve key evidence which could mean that dangerous conditions or circumstances go undiscovered. You point out that this raises the prospect that appropriate steps to avoid a similar tragedy are overlooked. I am grateful to you for bringing your concern to my attention.
As a consequence of Mr Walters’ death and the discovery of HMP Exeter’s deficiencies with regard to the preservation of key evidence, new measures and processes have been put in place to prevent similar circumstances in the future. In particular, HMP Exeter have created a local operating policy for deaths in custody, which contains a list of essential documents that must be retained and the required actions. Included within the list is the collation of relevant cell bell records, CCTV and Body Worn Video Camera footage of any incident. Also, since Mr Walters’ death a new CCTV system has been installed which provides a more reliable source of footage.
In addition to the above, all deaths in custody at HMP Exeter are subject to a quick time learning review conducted by the Head of Safety and Regional Groups Safety Lead. This occurs within 72 hours of any apparent self-inflicted death taking place and as a result requires all pertinent information, including CCTV footage and cell bell records, to be made available and reviewed.
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 Exeter
Response Status
Linked responses
1 of 1
56-Day Deadline
22 Sep 2021
All responses received
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 14th July 2021 I commenced an inquest into the death of Carl Lee Walters aged 34. The investigation concluded at the end of the inquest on 21st July 2021. The conclusion of the inquest was that Mr Walters died as a result of intraperitoneal haemorrhage due to a ruptured splenic pseudoaneurysm of undetermined aetiology, the evidence not revealing whether this was naturally occurring or trauma related and if the latter whether the trauma arose out of an accidental blunt force impact or an assault.
Circumstances of the Death
Mr Walters died suddenly and unexpectedly in his cell. The cause of his death was a ruptured splenic pseudoaneurysm which was most likely to have been trauma related. Although there was no evidence to the effect that Mr Walters had been injured whilst he was in prison the possibility nevertheless existed. As such it was very important that prison CCTV footage should be examined. Further, Mr Walters’ cellmate alleged that he had pressed the emergency cell bell on numerous occasions. However, despite the provisions of Chapter 12 of PSI 64/2011 CCTV images had not been preserved and only limited cell bell records had been kept.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.