Andrew Dean: Prevention of future deaths report

Suicide (from 2015)

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Date of report: 02/06/2023

Ref: 2023-0178

Deceased name: Andrew Dean

Coroner name: Michael Spencer

Coroner Area: East Sussex

Category: Suicide (from 2015)

This report is being sent to: HM Prison and Probation Service

HMP Lewes
The Ministry of Justice
I am Michael Spencer, Assistant Coroner for the coroner area of East Sussex.
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.
On 29 March 2021 I commenced an investigation into the death of Andrew DEAN aged 50. The investigation concluded at the end of the inquest on 31 March 2023. The jury recorded a conclusion of SUICIDE.
On 26th March 2021 at approximately 10.11am in cell A3-10 at HMP Lewes, Andrew Dean was found with a ligature around his neck [REDACTED]. He was treated at the scene by prison staff, healthcare staff and paramedics.
Andrew Dean was declared dead at 11.27am at HMP Lewes.
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:  
Following his arrival at HMP Lewes on 24 March 2021, Mr Dean was offered and attempted to make his initial first nightphone call but did not manage to speak to anyone. Over the next 36 hours, he made requests of prison staff for another opportunity to make a phone call, which were refused. During the same period, his partner tried to contact the prison through the prison switchboard, but was not able to make any contact with him. In his suicide note to his partner, Mr Dean wrote “I tried to get to talk to you but these lot here wouldn’t let me.   I am concerned that there are no clearly defined processes to ensure that new prisoners can successfully make first contact with family members (when this does not take place on the first night) and for logging and handling incoming calls to the central switchboard from family members with concerns about a prisoners safety and/or requesting a welfare check.

Following the inquest, I gave the Ministry of Justice an opportunity to address these concerns by providing further evidence of any new procedures that have been put in place since Andrew Deans death, but they declined to do so. In my view, these are matters that require further consideration by the Ministry of Justice and HMP Lewes to avoid a risk of future deaths through self-harm or suicide. I refer to the enclosed letter from the solicitors for Mr Deans partner dated 19 May 2023.
In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 31 July 2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
1.     Andrew Deans partner
2.     Andrew Deans brother
3.     Practice Plus Group.
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.
Michael SPENCER Assistant Coroner for East Sussex