Johnpaul Digweed: Prevention of future deaths report

You are under a duty to respond to this report within 56 days of the date of this report, namely  by 24 August 2026. I, the coroner, may extend the period if an appropriate application is made.

I have a duty to send a copy of your response to the Chief Coroner.
In accordance with the Chief Coroner’s Publication Policy, you should send me any  representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. 

Please note any links to webpages included in the response will not be  checked for sensitive information prior to publication, as the information is already online. 

The names of those who do not respond to PFD reports are regularly published on the Chief  Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary. 

2.   Evidence was heard that there is a regular practice of prisoner’s covering their  observation panels in their cell doors at HMP Garth. Despite Governor’s Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not  aware of the instructions which were issued by email. As a result, the orders and  notices have been updated and reissued by email clarifying expectations in relation to  welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that  there was any system outside the email system to ensure important information is  cascaded and seen by affected staff. In addition, whilst the amended instructions  confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required . 

The medical cause of death was 1a Hanging  
How, when and where see Conclusion  
Conclusion 

Mr DIGWEED died between 17:06 on 12 April 2024 and 11:31 on 13 April 2024 at HMP Garth, Leyland. The cause of death was suicide by hanging. Mr DIGWEED was found hanging in his cell. He took deliberate steps to end his life and intended to do so. [REDACTED]. Numerous opportunities were missed in the months prior to Mr DIGWEED’s death to assess his mental 
state and provide appropriate support. Routine prison procedures to monitor welfare were not  carried out as per prison policy and mandatory governor’s orders. The gaps in care possibly  contributed to Mr DIGWEED’s death. The observations on 12-13 April 2024 were also not  carried out as per prison policy and mandatory governor’s orders. A prisoner discovered Mr  DIGWEED’s body. Staff attempted resuscitation but rigor mortis had set in and attempts were  futile 

The MATTERS OF CONCERN are as follows: 
[250-word statement addressing what circumstances of the death have led to the coroner’s  concern, and why the coroner thinks the person to whom the report is directed is responsible  for taking action to prevent future deaths. This statement must not propose what action should be taken, as coroners cannot make recommendations]. 

1.   Evidence was heard that despite several staff being aware of incidents of self-harm involving a prisoner at HMP Garth an Assessment, Care in Custody Teamwork  process (ACCT) was not opened. Whilst evidence was provided that staff are trained  as part of their induction program and that training materials is available to staff, no  assurance could be given that there was any ongoing mandatory refresher training or any system in place to monitor understanding that every member of staff is  responsible for opening an ACCT where required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent  future deaths   

2.   Evidence was heard that there is a regular practice of prisoner’s covering their  observation panels in their cell doors at HMP Garth. Despite Governor’s Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not  aware of the instructions which were issued by email. As a result, the orders and  notices have been updated and reissued by email clarifying expectations in relation to  welfare checks and steps requires if observations panels are obscured. However, no  assurance could be given that staff had read and understood the instructions or that  there was any system outside the email system to ensure important information is  cascaded and seen by affected staff. In addition, whilst the amended instructions  confirm a verbal response is mandatory for welfare checks, they do not explicitly state  a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent  future deaths 

I also may send a copy of the report to any other person who I believe may find it useful or of interest. 

I can confirm I have sent the report to:
1.Family of Mr Digweed  2.Healthcare provider at HMP Garth

I also have a duty to send a copy of the report to the Chief Coroner.

You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be  sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional  information relating to the publication of reports and responses.