Kyle Nel · Prevention of Future Deaths report

On the 13th June 2018, an investigation was commenced into the death of Kyle Nel, born on the 27th February 1986.

The investigation concluded at the end of the Inquest on the 14th December 2021.

The Medical Cause of Death was:

1a Aspiration of gastric contents associated with synthetic cannabinoid (5F-ADB) also known as “Spice” use.

The conclusion of the Inquest recorded:

Misadventure

On the 9th June 2018 Kyle, a serving prisoner at HMP Guys Marsh, was found unconscious in his cell 29 on Jubilee wing by his cell mate. The alarm was raised and prison officers attended and CPR was administered, paramedics attended they continued to try to resuscitate him but Kyle was subsequently declared dead.

1. During the inquest evidence was heard that:

i. Concerns about Kyle, his use of PS, the bullying he was subject to and the debts that he incurred, were raised with the prison staff by his mother. Whilst his mother was able to speak to a member of the prison staff, the quality of the response gives rise to concern. The prison has introduced a number of different measures aimed at tackling anti- social behaviour and bullying. There is the Tackling Anti-Social Attitudes (TASA) policy. This is a three- tiered approach dependant on the incident. This ranged from monitoring to consideration of being moved to the segregation unit in the most serious cases. There is also the Custodial Violence Management Model (CVMM). This is a case management approach for managing violent and significantly problematic custodial behaviour. HMP Guys Marsh was the pilot for this scheme. This introduced a specific CNOMIS case note for those who were being managed under the CVMM to allow for entries to be recorded electronically.

ii. Evidence was heard that between the various units at the prison there are fences but that prisoners can pass items through the fences between one unit and another. This enables drugs and other prohibited items to be transferred between units. The evidence heard is that this issue is known about but no action has been taken.

2. I have concerns with regard to the following:

i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented.

ii) The security fences within the prison estate need to be reviewed and consideration urgently given to prevent drugs and other prohibited materials being passed between prisoners through the fences.