Dear Mr Rebello, Re: Regulation 28 report concerning the inquest into the death of Mr Connor Smith at HMP Altcourse on 2 January 2013 Thank you for your regulation 28 report of 17 December 2014, addressed to Nigel Newcomen, the Prisons and Probation Ombudsman, about the inquest into the death of Mr Connor Smith at HMP Altcourse on 2 January 2013. am responding, as the Deputy Ombudsman responsible for investigations into deaths in custody. Your report identified an apparent minor factual inaccuracy in the PPO report;, in that the inquest heard evidence that an officer who was listed as being present at a segregation review, and told the PPO investigator that he was present; appears not to have attended the meeting after all. our investigation, no other attendees listed as present at the meeting, said that the officer was not there and no one from the prison corrected this when the draft report went to them for fact check_ While obviously, we would prefer our reports to be entirely accurate, in these circumstances, this was the responsibility of the fficer and the prison. There was no reason for the investigator to disbelieve the evidence at the time understand the officer did not give evidence at the inquest; but when interviewed; he told the investigator several times that he was at the review_ We regard the apparent inaccuracy as minor; as we took no account of the officer's evidence about the review in reaching our conclusions and we consider it had no material bearing on the circumstances of Mr Smith's death: As you know, this office is committed to helping avoid any future deaths in custody, but am not clear how we can take any action in relation to the matter you identify which might help avoid any future fatality, which is the avowed purpose of regulation 28 reports_ Ultimately, the services we investigate are responsible for safeguarding those in custody: We can only realistically contribute to preventing a reoccurrence of the circumstances of Mr Smith'$ death through the recommendations made in our investigation reports_ For that reason, the memorandum of understanding between the PPO and the Coroners' Society recognises that because of our role it 'would be unusual for the conduct of the investigation by the PPO to come within [a Regulation 28] report' . PO Box 70769, London, SEIP 4XY Tel: E-mail: mail@ppo.gsi.gov.uk WWw ppo:gov.uk City = During being fully

In the sad circumstances of Mr Smith's death, the Ombudsman made four recommendations to the prison about assessment and management of depression, the operation of the Incentives and Earned Privileges scheme for people on basic, healthcare input into decisions about segregation and investigations into allegations about bullying, which we hope might prevent future similar deaths do not believe there is further specific action that the PPO can take_

Dear Mr Rebello Thank you for your Regulation 28 report dated 17 December 2104 addressed to the Secretary of State for Justice and to Michael Spurr, Chief Executive of the National Offender Management Service (NOMS) concerning the recent inquest into the death of Connor Smith on 2 January 2103. Your letter has been passed to the Equality, Rights and Decency Group in NOMS as we have responsibility for policy on suicide prevention and self harm management and for sharing learning from deaths in custody: understand that your concern relates to the quality of the investigation by the Prisons and Probation Ombudsman: However in raising that concern you have drawn attention to the fact that a member of staff was recorded as having attended a meeting at which he was not present, and would like to provide reassurance that this issue has been addressed by the Director of HMP Altcourse. A notice has been issued to all senior managers who chair Segregation Review Boards advising them that the documentation for completion at the meeting must not have names entered in advance and that it is their responsibility to check that attendance at the meeting is correctly recorded: that you find this information helpful: