The Senior Coroner for Buckinghamshire, Crispin Butler, has issued two comprehensive Prevention of Future Death reports requiring action from the Governor of HMP Woodhill, Central & North West London NHS Foundation Trust and Oxford Health NHS Trust following the inquest of Jack Portland, which found multi-agency failures in his care.
The coroner identified many concerns arising from the care Jack, 29, received and believes future lives are at risk. The three public bodies have 56 days to respond to the reports to set out the action they propose to take, or have taken, to reduce the risks to other lives.
Both reports cover not just failings in Jack’s care but also serious failures which occurred after his death: the inadequate responses of the public bodies to the concerns raised by Jack’s family and shortcomings in disclosure of documents for the purposes of the inquest.
One of the reports has identified risks that may lead to future deaths at HMP Woodhill and has been issued to the Governor of the prison and Central & North West London NHS Foundation Trust, which is responsible for the provision of certain healthcare services within the prison. The Coroner highlighted concerns about the completion of the documents used to assess and manage Jack’s risk of self-harm, the information provided to Jack’s family when he was identified as being at risk of self-harm and the assessment and management of Jack’s release from prison given he was homeless and not registered with a GP.
The second report identified risks at the Whiteleaf Centre, a mental health hospital, and has been issued to Oxford Health NHS Foundation Trust. Not only has the Coroner highlighted areas of concern spanning from the management of community leave processes to risk assessment, but the report addressed to the trust also finds the internal investigations conducted after Jack’s death were based on inaccurate information and took 11 months after the death to complete.
The Coroner stated, commenting on the two investigation reports completed by the trust into Jack’s death, that:
“The ability to react quickly to issues raised and to implement new policies and working practices may have been compromised by the delays and lack of robustness of the reports. The recommendations of the second [report]….do not appear to address more urgent practical action or possible staff training needs.”
An inquest was held into the death of Jack at Buckinghamshire Coroner’s Court between 23rd January and 3rd February 2017. The inquest jury concluded that there had been a range of failures by the public bodies responsible for keeping Jack safe when in custody and when sectioned under the Mental Health Act in hospital.
The Coroner has a legal duty to write a Prevention of Future Deaths report following an inquest if it appears there is a risk of other deaths occurring in similar circumstances.
Jack died on 27 December 2015 following a struggle with mental health issues and drug use. In April 2015 Jack was arrested for shoplifting and spent time in prison at HMP Woodhill. His parents visited him regularly and saw his mental health deteriorate.
He was released from the prison in October 2015 with only an arrangement of a week in B&B accommodation and a week’s worth of psychiatric medication. His parents believe he should not have been released from the prison as he was in a psychotic state. Shortly after his release Jack returned to prison at HMP Lewes and then spent time at two mental health facilities, The Dene in West Sussex and The Whiteleaf Centre in Aylesbury.
Throughout this time his parents continued to visit him regularly and raised their concerns over his mental health to staff at the prison, the police, then Secretary of State Michael Gove and staff at the mental health facilities.
Jack died while on one-hour unescorted community leave from The Whiteleaf Centre and his absence went unnoticed for an hour-and-a-half after he was due to return. The Police were not called for over two hours. His family were never informed he was missing.
Jack’s family said in a statement:
“We have always hoped that by raising our concerns about Jack’s experience that it would lead to other people in a similar situation receiving better care and reduce the chances of another family going through what we have.
"We are grateful to the Coroner for issuing these powerful reports to the public bodies involved and hope they have the intended effect of preventing future deaths of vulnerable people.”
Merry Varney, of law firm Leigh Day, represented Jack’s family at the inquest.
She said: “We welcome the Coroner’s decision to issue two Prevention of Future Death reports in this case.
“These reports show that the failings of the agencies involved in Jack’s care were so serious and that action must be taken to prevent the unnecessary deaths of others under their care. Producing these public reports is such an important function of a Coroner and we hope that swift and strong action is taken in relation to the concerns that have been raised in these reports.
“Patients detained due to mental ill heath deserve better and the highlighting by the Coroner of the failings in the Trust’s post-death conduct shows the struggle bereaved families have when seeking answers about their loved one’s death.”
“It is crucial that the risks to people with a history of mental illness and self-harm are robustly assessed and managed, both whilst in prison and upon their release. Otherwise, the results can be tragic. The Coroner’s report underlines the importance of this and asks for action to be make sure that it is achieved.”
The family were represented by Caoilfhionn Gallagher QC of Doughty Street Chambers and Merry Varney and Benjamin Burrows of Leigh Day, members of the Inquest Lawyers Group.