Police sergeant among accused in manslaughter trial over death in custody

Kingshott, Marsden, Tansley
Kingshott, Marsden, Tansley

A police custody sergeant and two detention officers are to go on trial accused of killing a schizophrenic church caretaker who collapsed while in custody.

Sergeant Jan Kingshott, 44, and civilian staff Simon Tansley, 38, and Michael Marsden, 55, face trial at Bristol Crown Court.

The three defendants each deny two joint charges of the manslaughter of Thomas Orchard.

The first charge alleges that on October 10 2012 they did an act or series of acts which unlawfully killed Mr Orchard.

The second charge alleges that on the same day the Devon and Cornwall officers unlawfully killed Mr Orchard by gross negligence.

Mr Orchard died in hospital seven days after he was allegedly restrained at Exeter’s main police station having been earlier arrested on suspicion of a public order offence.

The trial is expected to last up to seven weeks before High Court Judge Mr Justice King.

Deaths in custody “were avoidable”

deaths-in-custody

The deaths in custody of hundreds of people with mental health problems could have been avoided, according to an inquiry.

Repeated basic errors, poor communication and a lack of rigorous procedures were found to have contributed to deaths in police cells, prisons and psychiatric hospitals.

The Equality and Human Rights Commission (EHRC) examined the period from 2010-13, during which it said 367 adults with mental health conditions died of non-natural causes in psychiatric wards and police cells, while 295 adults died in prison, many of whom had mental health conditions.

The EHRC has recommended a framework aimed at policy makers and front-line staff to help protect people in custody.

Professor Swaran Singh, lead commissioner on the inquiry, said: “Human rights are for all of us and nothing is more fundamental than our right to life.

“When the state detains people for their own good or the safety of others it has a very high level of responsibility to ensure their life is protected.

“For people with mental health conditions that is a particular challenge with a large number of tragic cases over the past few years where that responsibility has not been met.

“The commission, as Great Britain’s national human rights institution, carried out this inquiry in consultation with other expert bodies to examine what lessons can be learned and how to prevent further unnecessary and avoidable harm and heartbreak.”

The report found basic mistakes were repeated, such as failing to properly monitor patients and prisoners at serious risk of suicide, and not removing ligature points in psychiatric hospitals despite their common use in suicide attempts.

Misplaced concerns about data protection were blamed for prison healthcare staff not telling officers on the wing that an inmate had suicidal tendencies. A failure to update patients’ risk assessments was also criticised.

A central record is kept of the deaths of people with mental health issues in prisons and police stations, but not in hospitals. The EHRC noted that there is no independent body charged with ensuring that effective investigations take place in the latter, and claimed some staff feel they cannot speak out openly.

The commission made a number of recommendations such as setting up trigger systems to alert staff to events or dates which could prompt self-harm, such as the anniversary of a bereavement, and embedding a mental health liaison officer in each police force.

Inspector Michael Brown, co-ordinator for mental health at the College of Policing, said: “There is a growing demand on front-line police officers and staff in helping those of us suffering mental health difficulties.

“While the police service should not be filling gaps in mental health services we need to ensure that we give front-line officers and staff basic training in identifying signs and symptoms.

“Officers and staff also need to be equipped with the knowledge of where to divert vulnerable people into a healthcare setting so that they can receive expert care. That means not using police cells as a place of safety for those detained in distress.”

INQUEST response to the YJB Child Deaths Report

INQUEST Charitable Trust
INQUEST Charitable Trust

INQUEST response to Youth Justice Board report on deaths of children in custody

Deborah Coles, co-director of INQUEST said:

“Whilst this report offers some insight into the Board’s learning from child deaths, it can be no substitute for a wider review.

“INQUEST’s work on the deaths of children shows the same issues of concern repeat themselves with depressing regularity. This demonstrates that the current mechanisms, including the YJB, are not preventing deaths of children.

“And recent government proposals relating to restraint and secure colleges for children also call into question the extent of the impact the YJB’s learning is having on policy-making.

“A short report cannot be a substitute for a full, holistic, independent review of child deaths in custody that encompasses all findings and recommendations, and examines the wider public health and welfare issues and a child’s journey into the prison system.  The government must extend the remit of the inquiry it is commissioning into the deaths of 18-24 year olds in prison to include children.”

Notes to editors:

1.  The YJB report can be accessed here: http://www.justice.gov.uk/youth-justice/monitoring-performance/serious-incidents

2.  The Criminal Justice and Courts Bill can be accessed here: http://services.parliament.uk/bills/2013-14/criminaljusticeandcourts.html

3. INQUEST’s briefing on the need for an independent review of the deaths of children and young people can be accessed here  

For further information, please contact Hannah Ward, INQUEST Communications Manager on 020 7263 1111 / 07972 492 230.

INQUEST provides a general telephone advice, support and information service to any bereaved person facing an inquest and a free, in-depth complex casework service on deaths in custody/state detention or involving state agents and works on other cases that also engage article 2 of the ECHR and/or raise wider issues of state and corporate accountability. INQUEST’s policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths occurring.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.

YJB Child Deaths In Custody – Lessons Learnt Report published

yjb-dic-p1

The YJB’s report Deaths of Children in Custody: Action Taken, Lessons Learnt explains the actions taken by the YJB in response to recommendations made by the Prisons and Probation Ombudsman, coroners and Serious Case Reviews, following the deaths of children in custody since 2000. It also identifies the work that still needs to be undertaken to ensure that when children must be held in custody, it is in a safe environment which protects them from harm.

Holme House Prison Damned By Inquest Jury

holme-house

In a damning verdict returned late on Thursday 13 June, the jury in the inquest into the death of Andrew Hall on 27 March 2009 found that he took his own life whilst the balance of his mind was disturbed, contributed to by neglect.

This is the third short form neglect verdict returned following a self inflicted death at Holme House prison.

Following three full weeks of evidence, the lengthy jury verdict listed 21 separate failures of Andrew Hall’s care and treatment at HMP Holme House. These included failures in risk assessment and risk management, and serious failures in communication. 

Andrew served part of his sentence at HMP Kirklevington.  Whilst there, he had attempted suicide by cutting both wrists.  Following a period of hospitalisation he was transferred to Holme House prison on an open ACCT (Assessment, Care in Custody, and Teamwork – the system used for prisoners who are at risk of self harm), which was subsequently closed.  The jury concluded that this ACCT should not have been closed.  Following the (improper) closure of the ACCT, on 23 March, Andrew was further assessed by a psychiatrist who considered him to be psychotic and at significant risk of self harm. Despite this, no ACCT was re-opened, a clear failure identified by the jury.  The jury found that none of the nurses in the subsequent four days had read the psychiatrist’s documented assessment. As a consequence, he was not afforded the level of observations, interaction and care necessary.

As a result, despite being in a camera cell, he was not being properly observed when he first inflicted a wound to his neck four days later.  The jury concluded that the failure to observe and interact contributed to his death.  In a devastating criticism, the jury also found ‘there was an opportunity for the staff to intervene between the time when he inflicted a wound to the vein in his neck and the time when he inflicted a wound to the artery in his neck’.  This period lasted around 20 minutes, during which blood could be seen on CCTV on the floor of the cell.

The full verdict is available from INQUEST.

At the conclusion of the inquest, the deputy coroner indicated that he would be reviewing recommendations made following previous inquests into deaths at HMP Holme House before drafting his own, with specific reference to continuing failures of record keeping and communications between discipline staff, nursing staff and the mental health in-reach team.  Since Andrew Hall died, there have been five further self-inflicted deaths at HMP Holme House. 

Paula Davidson, Andrew’s partner said:

“The verdict today has proven Andrew’s death was unnecessary and if individuals had carried out their roles there would not have been failings in his care which resulted in Andrew’s death

“There have been a number of deaths before and after Andrew’s death and we hope that lessons have been learned from today’s verdict which the jury have returned.

“I would not have the truth for the family and also for our little girl today if it had not been for the support from INQUEST and I would like to thank them and Fiona Borrill and Imogen Hamblin from Lester Morrill solicitors and Sean Horstead from Garden Court Chambers for all their support throughout this four year experience.”

Deborah Coles, co-director of INQUEST said:

“Had greater care been taken been taken of Andrew this tragic and disturbing death might not have happened at all.

“The fact that this is the third neglect verdict since 2004 at HMP Holme House should be a wake up call to the prison service.  Moreover, that there have been five further self inflicted deaths there since Andrew Hall died in March 2009 suggests that little has been done to address the issues raised at this and previous inquests.

“It is crucial for the safety of all prisoners at Holme House that these failings are addressed as a matter of urgency.”

The family is represented by INQUEST Lawyers Group members Fiona Borrill and Imogen Hamblin from Lester Morrill solicitors and barrister Sean Horstead of Garden Court Chambers. The same team represented the families of the two other self-inflicted deaths at HMP Holme House where neglect verdicts were returned at inquest.

Ends

Notes to editors:

1.  Full background on Andrew Hall’s death can be accessed here

2.  The full jury verdict is available from INQUEST.  Please contact Hannah Ward.

For further information, please contact: Hannah Ward, Communications Manager at INQUEST on 020 7263 1111/07972 492 230 or hannahward@inquest.org.uk

INQUEST provides a general telephone advice, support and information service to any bereaved person facing an inquest and a free, in-depth complex casework service on deaths in custody/state detention or involving state agents and works on other cases that also engage article 2 of the ECHR and/or raise wider issues of state and corporate accountability. INQUEST’s policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths occurring.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.