Douglas Birch · Prevention of Future Deaths report

On 22nd May 2013 I commenced an investigation into the death of Douglas Birch, 46. The investigation concluded at the end of the inquest on 9th July 2015. The conclusion of the inquest was that Douglas Birch died in his bed at HMP Swaleside between the hours of 19.10 on 14th May 2013 and 07.10 on 15th May 2013 of sudden arrhythmic death syndrome. He was found at 12.20 on 15th May 2013 by prison officers

Douglas Birch was a serving prisoner at HMP Swaleside in a single occupancy cell. On 15th May 2013 after a roll call at 7.10, the cells were unlocked at 08.15 for 30 minutes domestics before being locked again at 08.45. The cells were unlocked at approximately11.35 for lunch and locked again at approximately 12.10. His dead body was not discovered until 12.20 after a prison officer who had delivered mail to his cell without receiving a response raised concerns with a senior officer and the cell was entered. The state of his body was such that it could be established that he had been dead for a number of hours and likely before 08.00. No officer responsible for locking or unlocking his cell had sought to elicit a response from him, believing him to be asleep at the time. This was in contravention of PSI 75/2011

(1) Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response from the prisoner upon unlocking a cell or were aware but did not act in accordance with the order especially where they assumed the prisoner was asleep
(2) Prison officers were either not receiving Prison Service Orders and Instructions or if they did receive them, did not read them