UK Inquiry Tracker

Joanna Daly

PFD Report All Responded Ref: 2021-0245

Date of Report 16 July 2021

Coroner John Hobson

Coroner Area West Yorkshire (Eastern)

Response Deadline ✓ from report 22 September 2021

Alcohol, drug and medication related deaths State Custody related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 22 Sep 2021

Coroner's Concerns (AI summary)

Prison staff conducting welfare checks on vulnerable first-night prisoners lack specific guidance, raising concerns about the quality and effectiveness of these critical observations.

View full coroner's concerns

The matter of concern is as follows: During the course of the Inquest, the matter of checks undertaken by healthcare staff on prisoners resident for their first night in the prison's First Night Centre was heard in evidence. The jury found that no guidance as to how such checks were to be conducted had been provided to the staff undertaking the checks, and that it was possible that this contributed to Joanna's death. Since Joanna's death, changes within HMP New Hall have been undertaken whereby welfare checks undertaken at the First Night Centre are now completed by prison staff. The new arrangements have been in place since October 2020. Whilst evidence was provided of the key times at which such checks are undertaken, it became apparent that there was no specific guidance provided to prison staff to explain what was required to be undertaken during a welfare check. The particular vulnerability of prisoners resident on the First Night Centre is the reason for such checks. I am concerned about the absence of any specific guidance, in view of the findings of the jury in relation to the night checks that were previously undertaken by the healthcare staff at the time of Joanna's death. This could impact upon the quality of the welfare checks that are now undertaken by the prison staff, in the context of the First Night Centre where prisoners may be particularly vulnerable. I am under a duty to report this matter upon consideration of the evidence as provided to the court.

Responses

HM Prison and Probation Service Central Government

22 Sep 2021

Action Taken
HMP New Hall introduced new processes in July 2021 to improve the quality of welfare checks, including requiring a response from residents in the First Night Centre and clarifying the purpose and requirements of the checks in a notice to staff and local operating instructions. (AI summary)

View full response

Dear Mr Hobson,

Thank you for your Regulation 28 Report dated 16 July 2021 addressed to the Ministry of Justice following the inquest into the death of Joanna Daly at HMP New Hall on 02 June 2019. I am responding as Director General for Prisons.

I know that you will share a copy of this response with Ms Daly’s family, and I would like to first express my sincere condolences for their loss, every death in custody is a tragedy.

You have expressed concern that there is no specific guidance provided to prison staff regarding what is required to be undertaken during a welfare check.

Since Ms Daly’s death, HMP New Hall has introduced new processes to improve the quality of welfare checks. In July 2021, a notice to staff was issued covering First Night Centre welfare checks during night state – most easily described to those not familiar with the term as the time during the night whereby all people in custody are residing within their cells and no activity occurs out of cell. The notice revised previous instructions and clarified that staff must now obtain a response from a resident in the First Night Centre. The notice details the times welfare checks should take place, the purpose of the welfare check and what is required from a welfare check. It also reminds staff to create a record summary for all those in custody during the night state on the National Offender Management Information System (an electronic record of all individuals in custody). These changes have also been included in HMP New Hall’s local operating instructions, which were published in July 2021.

Thank you again for bringing your concern to my attention. I trust that this response provides assurance that this is an issue that we take seriously, and that appropriate action has been taken.

Sent To

Ministry of Justice

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 4th June 2019, an investigation was commenced into the death of Miss Joanna Daly, aged 35. The investigation concluded at the end of the Inquest held before a jury on 6 July 2021. The jury recorded that the medical cause of death was: 1 a Ventricular arrhythmia leading to cardiac arrest 1 b Use of illicit cocaine A narrative conclusion was recorded by the jury as follows: 'Joanna's death was drug related. The roll checks carried out by prison staff were adequate. The healthcare checks were not carried out adequately and this could have been a contributing factor to her death'.

Circumstances of the Death

On 1 June 2018 Miss Joanna Daly was admitted to HMP New Hall following a breach of licence conditions following previous sentencing. She had been released from HMP New Hall on 20 May 2018. Upon arrival, it was noted that she was experiencing withdrawal from drugs. Following nursing and medical assessment, she was taken to the First Night Centre. As with all first night prisoners, night checks were undertaken by healthcare staff. Roll checks were conducted by prison staff. On the morning of 2 June 2019, Miss Daly was found unresponsive in her cell and her death was confirmed.

Copies Sent To

and Practice Plus Group who were Interested Parties at the Inquest

Inquest Conclusion

'Joanna's death was drug related. The roll checks carried out by prison staff were adequate. The healthcare checks were not carried out adequately and this could have been a contributing factor to her death'.