Carl Newman

PFD Report All Responded Ref: 2020-0056
Date of Report 6 March 2020
Coroner Andre Rebello
Response Deadline ✓ from report 1 May 2020
All 1 response received · Deadline: 1 May 2020
Coroner's Concerns (AI summary)
Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue with tracking and ensuring current staff competence.
View full coroner's concerns
The MATTERS OF CONCERNS are as follows: During the Course of evidence it became apparent that prison staff did not have ready access to training records in particular ACCT & SASH training – one officer engaged in prison reception processes had not had ACCT training for over three years – and surprisingly it was another three years before he underwent SASH training. As HMP Liverpool were present throughout this investigation, the court understands that these training issues are being resolved locally. However this is a national issue and It is important that not only should HMPPS hold training records for those employed in the prison service but that each individual should have a personal training record. It would help if training certificates with expiry dates were issued after all courses with a copy being given to attendees and the record being held by the prison service. This would ensure all officers with current training could work across the prison estate, adding resilience. What does HMPPS intend to do to ensure that all officers and staff have current training in ACCT and other safer custody processes?
Responses
HM Prison and Probation Service Central Government
27 Oct 2020
Action Taken
Following the inquest, the Governor of HMP Liverpool issued a staff information notice promoting the use of the myLearning system for accessing training records, and a comprehensive guide on how to use the system will follow. The ACCT case management system is being updated and training packages refreshed. (AI summary)
View full response
Dear Mr Rebello Thank you for your Regulation 28 Report of 6 March 2020, following the recent inquest into the death of Carl Newman at HMP Liverpool on 6 October 2017. I know that you will share a copy of this response with Mr Newman’s family and I would like first 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 expressed concern that evidence given during the inquest indicated that staff at HMP Liverpool were unaware of how to access their personal training records, and suggested that this may also be an issue in other prisons. You also asked what actions HMPPS is taking to ensure that all staff have up to date training in ACCT and other safer custody processes. All training courses – both those organised centrally by the national Learning and Development team (including ACCT case manager training) and those provided locally at establishment level (including the various modules of the Introduction to Suicide and Self-Harm Prevention training) – are recorded on myLearning, the HMPPS national learning database. Staff enrol on a course using this system, and

on successful completion of the training, their record is updated to reflect their attendance (and pass/fail outcome for some courses). Both the learner themselves and the local training department have access to this record. Training departments are also able to run a report to see who has attended and/or passed a particular course, and when. We consider that this electronic system achieves the same outcomes as the system of certificates with expiry dates that you mention in your letter. As a result of the matters that arose at the inquest, the Governor of HMP Liverpool has issued a staff information notice to promote the use of the myLearning system, and staff have been reminded that they are able to view their personal training records on it. This notice reiterates the importance of staff knowing when they need to undertake any future refresher training and will shortly be followed up with a comprehensive guide on how to use the system. There is also a local training co­ ordinator who is available to assist staff with queries about these issues, and has responsibility for ensuring that staff are able to attend refresher training as required. As you know, we intend to roll out a new version of the ACCT case management system soon, and we will be taking this opportunity to update the related training packages, and to refresh our approach to safety training more broadly. This will allow us to reduce duplication between courses whilst ensuring that the content is consistent and makes appropriate links between related issues. As we develop this new set of training materials we will ensure that expectations as to which staff should attend which courses, and the frequency of refresher training, are clear. Thank you again for bringing these matters of concern to my attention. We will ensure that learning from this tragic incident is shared widely across the prison estate.
Sent To
  • HMPPS
Response Status
Linked responses 1 of 1
56-Day Deadline 1 May 2020
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 11/10/2017 I commenced an investigation into the death of Carl John Newman aged 23. The investigation concluded at the end of the inquest held from the 2nd to the 6th March 2020. The jury conclusion of the inquest was: Carl John Newman died by suicide The medical cause of death was found as: I a Compression of the neck I b Hanging I c ------------------ II -------------------
Circumstances of the Death
The Jury found: During admission to 68 Hornby Road, Liverpool on the 3rd October 2017 the Person Escort Form indicated that there was no immediate self-harm risks to Carl John Newman, also the Cell Sharing Risk Assessment concluded there was more of a risk to others as opposed to himself. Further, a medical assessment filed by the Mental Health Nurse also drew the conclusion that there was no current risk to himself. The majority of witness statements indicate that Carl Newman was not distraught during his time in the Induction Unit. After 3rd October 2017, there was no known indicators of risk. However, the Day Two Assessment had not been completed in a timely manner, which may have flagged any potential risks. Between the hours of 9.26am and 9.53am on the 6th October 2017, texts were received and statements indicate that calls were also exchanged between Carl and his former partner. On the 6th October 2017 between the hours of 9.30am and 11.30am, a ligature was fashioned around Carl Newman's neck in the toilet area of cell A5/11. It is believed Carl John Newman initiated this act with the intention of ending his life.
Action Should Be Taken
7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 01 May 2020. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Carl John Newman HMP Liverpool Spectrum – Healthcare Care provider at HMP Liverpool I have also sent it to The Prison and Probation Ombudsman and HM Inspectorate of Prisons Both at Third Floor, 10 South Colonnade, London E14 4PU who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Andre REBELLO Senior Coroner for Liverpool and Wirral Dated: 06 March 2020
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.