Nathan Shepherd: Prevention of Future Deaths Report

State Custody related deathsSuicide (from 2015)

Skip to related content

Date of report: 22/01/2025 

Ref: 2025-0038 

Deceased name: Nathan Shepherd 

Coroners name: Alison Mutch 

Coroners Area: Manchester South 

Category: Suicide (from 2015) | State Custody related deaths

This report is being sent to: Ministry of Justice

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Ministry of Justice
1CORONER

I am Alison Mutch , senior coroner, for the coroner area of Manchester South
2CORONER’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. 
3INVESTIGATION and INQUEST

On 17th January 2024 I commenced an investigation into the death of Nathan  Harry SHEPHERD. The investigation concluded at the end of the inquest on 20th December2024. The conclusion of the inquest was suicide and the medical  cause of death was 1a) Hypoxic brain injury 1b) Hanging. 
4CIRCUMSTANCES OF THE DEATH

Nathan Harry Shepherd had a history of mental health issues and drug use.  Whilst in custody in 2023 he was subject to an ACCT following him taking an  excess amount of medication in his cell. His calls were recorded from June 2023  and indicated he was using drugs and that his mental health fluctuated. On 8th  January 2024 he was released from custody to approved premises at Ascot  House. He was allocated a single room at Ascot House, he did not indicate any  immediate thoughts of suicide or self-harm to staff. The full extent of his mental health history and ACCT history was not known to the staff at Ascot House. This  was due to poor information sharing by probation service staff, this probably 
did not contribute to his death. On 11th January 2024 he sent a series of  messages to other residents which demonstrated he was deteriorating. Staff  were unaware of those messages. Ascot House overnight was staffed by one  member of probation and an agency worker. Both were required to be first aid  trained. On 11th January a text message was sent by Nathan Shepherd to the  landline in the office at Ascot House. It caused the phone to ring and the  message said the door was blocked and he was hanging. It was acted on by the  member of staff going straight to Nathan Shepherd’s room. An attempt to gain  entry was unsuccessful because he had barricaded himself into the room. The  barricading of entry to the room was made possible because the furniture was  moveable. Attempts were made to force entry. After approximately 12 and a half minutes, entry was gained, and Nathan Shepherd was found suspended  from a ligature. Entry would have been gained immediately had he not been  able to barricade himself into his room. The staff cut the ligature on entry releasing the compression and began CPR. Paramedic assistance arrived  approximately within 10 minutes after the staff gained entry. CPR continued  along with attempts to intubate him. Intubation was unsuccessful until the  arrival of a critical care paramedic. Successful intubation was followed by a  return of spontaneous circulation at 06:38. He was transported to Stepping Hill Hospital where a CT scan 08:35 showed extensive loss of grey-white matter  differentiation indicating an anoxic brain injury. He was moved to the critical  care unit. On 15th January a further scan showed that the position had  deteriorated further and he had a hypoxic brain injury that was not compatible with life. He died at Stepping Hill Hospital on 16th January 2024.  
5CORONER’S CONCERNS

During the course of the inquest the evidence 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. –  

1.  The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at  Approved Premises. This meant that staff did not have training on how  to deal with a situation. The inquest was told that the Probation Service were now developing such a policy but it had not been signed off or  rolled out to staff.  

2.  A copy of the draft policy was available to the inquest but it was unclear what if any discussion there had been with Police Forces and how it  would link in with Police policies such as the GMP Right Care Policy. 

3.  The evidence before the inquest was that Mr Shepherd was able to  barricade himself with relative ease due to the mobility of the furniture in his room. The Approved Premises had no clear policy regarding  furniture which meant that furniture could be used to create a barricade with relative ease. 

4.  The [REDACTED] was a ligature point. Such ligature points remained in the Approved premises. It was unclear if changes  could be made to reduce the risk they presented. 

5.  Agency staff were used under a national contract. The evidence before the inquest was that at the time of Mr Shepherd’s death there was no  policy for ensuring they could deliver CPR / First Aid. It was part of the national contract that they should be so trained but there were no checks to ensure that this part of the contract was being followed. The  evidence at the inquest was that the agency worker in place on the night did not appear able to deliver CPR. 

6.  Evidence from Probation and Prison staff showed a lack of  understanding of how the prison system could update the probation system and where that information could be found. This meant that key information was not shared effectively creating a risk that probation  staff in the community would not have a full picture of risk. 

7.  The inquest heard evidence that the information shared with the  Approved Premises staff by other probation staff was not accurate and did not give a full picture of risk. This was in part due to the fact that it  appeared key documents were being regularly completed by probation staff who were not the allocated probation officer and so were  unfamiliar with the history. 
6ACTION SHOULD BE TAKEN

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.  
7YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 19th March 2025. 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. 
8COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following  Interested Persons mother of Mr Shepherd on behalf of the family. I have also sent it to GMP, Prisons & Probation Ombudsman (PPO), HMP Berwyn &  Probation Services who may find it useful or of interest. 

I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or  summary form. They may send a copy of this report to any person who they  believe 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. 
9Alison Mutch 
HM Senior Coroner
22/01/2025