Regulation 28 Report: Unlawful Death of Terance Radford and Home Detention Curfew Concerns | Study notes Decision Making

Regulation 28 – After Inqu est

Document Template Updated 30/07/2021

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

NOTE: This form is to be use d after an inquest.

REGULA TION 28 RE PORT TO PREVENT DE ATHS

THIS RE PORT IS BE ING SE NT TO:

1 The Hono urable Victo ria Atkins QC MP, Mini ster of State (Ministry o f Justice) for

Priso ns and Probation

CORONER

I am Miss Laurinda Bower, Her Majesty’s Assistant Cor oner for the cor oner area of

Nottingham City and Nottinghamshire

CORONER’S LEGA L POWERS

I mak e this report under paragr aph 7, Schedule 5, of the Cor oners and Justice Act 2009 a nd

regulations 28 and 29 o f the Cor oners (Investigations) Regulations 2013.

INVESTIGAT ION and INQUEST

On 21 May 2019, I commence d an investiga tion into the death of Te rance Alfred RADFOR D,

aged 87 yea rs. The investigation c oncluded at the end o f the inques t on 14 January 2022.

The conclusion of the inque st wa s that:

At around 09.30 hours on 19 Apr il 2019, Mr Tera nce Alfred Radford was stood waiting at the

bus stop on Worce ster Avenue, Mansfield Woodhous e, Nottinghamshir e, when he was s truck

by a car, driven at spe ed dire ctly into co llision with him, by a ma le driver who had taken the

car from its o wner shortly be fore the said collision. Mr Radfo rd died at the scene as a result of

his injurie s.

Mr Radfo rd was unlawfully killed.

CIRCUMSTANCE S OF THE DEA TH (r estric ted to the cir cums tances relevant to this

repor t. A full note of the findings and concl usion has been s hared with this repor t )

On 20 Apr il 2020, a jur y sitting at Nottingham Crown Court, convicted of the

manslaughter of Terr y.

The inque st learne d that had been released from HMP Ra nby , Nottinghamshire,

less than 24 hours pr ior to Mr R adford’s death. His r elease from prison wa s contrary to the

national Home Detention Curfe w Policy Framework , because he was , at the material time,

awaiting the resolution of an Inde pende nt Prison Adjudic ation, dated 13 April 2019.

A dec ision to downgrade the lev el of adju dication from independ ent to internal, ma de by

three G overnors on 15 April 2019, not including the origina l decisio n-making Gov ernor, had

no basis in priso n policy or proce dure, and was drive n by a desire to circumv ent the term s of

postponement set out within the Hom e De tention Curfe w policy framewor k, in order to

relea se from custody on 18 Apr il 2019, rather than post -29 April 2019, when the

Indepe ndent Adjudication was due to be hea rd.

This dec ision provide d with the opportunity to bring a bout the dea th of Mr Rad ford

in the circum stances descr ibed above . But for the decision to release on Home

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Regulation 28 – After Inquest

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Honourable Victoria Atkins QC MP, Minister of State (Ministry of Justice) for Prisons and Probation 1 CORONER I am Miss Laurinda Bower, Her Majesty’s Assistant Coroner for the coroner area of Nottingham City and Nottinghamshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 21 May 2019, I commenced an investigation into the death of Terance Alfred RADFORD, aged 87 years. The investigation concluded at the end of the inquest on 14 January 2022. The conclusion of the inquest was that: At around 09.30 hours on 19 April 2019, Mr Terance Alfred Radford was stood waiting at the bus stop on Worcester Avenue, Mansfield Woodhouse, Nottinghamshire, when he was struck by a car, driven at speed directly into collision with him, by a male driver who had taken the car from its owner shortly before the said collision. Mr Radford died at the scene as a result of his injuries. Mr Radford was unlawfully killed. 4 CIRCUMSTANCES OF THE DEATH (restricted to the circumstances relevant to this report. A full note of the findings and conclusion has been shared with this report ) On 20 April 2020, a jury sitting at Nottingham Crown Court, convicted of the manslaughter of Terry. The inquest learned that had been released from HMP Ranby , Nottinghamshire, less than 24 hours prior to Mr Radford’s death. His release from prison was contrary to the national Home Detention Curfew Policy Framework, because he was, at the material time, awaiting the resolution of an Independent Prison Adjudication, dated 13 April 2019. A decision to downgrade the level of adjudication from independent to internal, made by three Governors on 15 April 2019, not including the original decision-making Governor, had no basis in prison policy or procedure, and was driven by a desire to circumvent the terms of postponement set out within the Home Detention Curfew policy framework, in order to release from custody on 18 April 2019, rather than post-29 April 2019, when the Independent Adjudication was due to be heard. This decision provided with the opportunity to bring about the death of Mr Radford in the circumstances described above. But for the decision to release on Home

Regulation 28 – After Inquest Dentention Curfew, Mr Radford would not have died when he did and in the manner he did. At the time of release from prison, he was considered by prison staff to pose a risk of causing harm to others, such that he could not be safely managed on the general residential block, and instead had been detained in the segregation unit since 29 March 2019. While in the segregation unit, he had continued to engage in behaviour that placed others at risk of harm, including fire setting and assault. At the material time, the Home Detention Curfew Policy Framework did not expressly prohibit prisoners from being released early from their sentence on home detention curfew directly from the segregation unit or on account of their behaviour while in custody. The Probation Support Officer had not completed a pre - release risk assessment, and had not considered any risks associated with his release above and beyond the suitability of the proposed release address. There was no information sharing between prison, mental health services and probation staff, that considered risk of harm to others on release, in the context of a prisoner who was known to have stopped taking his mental health medication and had disengaged from mental health services, who required isolation in the segregation unit due to his repeated violent outbursts, and who had displayed unusual and bizarre behaviour in the 48 hours prior to his release. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern)

The national Home Detention Curfew Policy Framework permits the release of eligible prisoners directly from the Prison's segregatio n unit , in circumstances where the prisoner has been placed in the segregation unit because the elevated risk of harm they pose to staff and other prisoners cannot be safely managed within the general prison population. The public may rightly be concerned that prisoners deemed ‘too risky’ to reside within the general prison population; with its strict curfews and regime, use of locked cells, and trained prison personnel with protective gear, can still be released early from their sentence under the terms of the Policy.
The national Home Detention Curfew Policy does not expressly require consideration or assessment of the prisoner’s risk of harm to others, beyond the suitability of the proposed release address. If a broader assessment of risk of harm to others is anticipated by the Policy, there is no guidance on who should complete the assessment (singular or multi-agency input), when it should be completed, and what factors ought to be considered as part of that assessment.
The national Home Detention Curfew Policy contains no framework for multi- agency information sharing with regards to the assessment and management of risk for those deemed eligible for early release under the terms of the Policy. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

Regulation 28 Report: Unlawful Death of Terance Radford and Home Detention Curfew Concerns, Study notes of Decision Making

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Regulation 28: REPORT TO PREVENT FUTURE DEATHS