Timothy John Shaw · Prevention of Future Deaths report

On 20 March 2017 I commenced an investigation into the death of Timothy John Shaw. The investigation concluded at the end of the inquest on 30 January 2018. The conclusion of the inquest was:-

Accidental death. The jury believe that with more resources and better communication further steps could possibly have been taken to manage Mr Shaw’s risk of dying and may have prevented his death.

Timothy Shaw, who was 34 years old at the time of his death, had a long history of offending and substance abuse. On 9 January 2017 he was remanded in custody to HM Prison Chelmsford. On 30 June 2017 he was sentenced to a 6 year imprisonment. During his time in custody he was subject to three ACCT processes. It would appear that during his time in prison, he was using drugs including prescription medication and morphine patches. On 19 February, he was found under the influence and on the morning of 28 February, he was found collapsed in his cell. He was taken to Broomfield Hospital and he died there on 2 March 2017. It would appear that no referral to the mental health service was made.

Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place.

The processes and systems for reducing access to illegal substances need to be improved and tightened up

The processes for referrals by both prisoners and staff to psychosocial services needs to be tightened up and improved.

The standard and accuracy of record keeping by both disciplinary and Healthcare staff needs to be improved.