Craig Bell
9 Mar 2015 · Coroner Nigel Meadows · Manchester City
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. unmet need for psychological therapies for prisoners with personality disorders
“The evidence established a significant unmet need for psychological therapies to treat patient prisoner suffering from personality disorders or those suffering from traits of such personality disorders. These prisoners are recognised as being at higher risk of self harm ( which may ultimately result in death ) or suicide. Without NHS Commissioners allocating more resources to identifying and treating such patients there is a concern that further prisoners suffering from these conditions will end”
2. lack of information sharing about risk and suicidal behaviour
“| am concerned that the appropriate sharing of information relating to risk and suicidal or self harming behaviour did not take place between the clinical team and HMPS staff. For example, the direct threat of suicide made at the review on the 27 November 2012 was not disclosed to HMPS staff. Appropriate, timely mutual information exchange had not taken place and there is a concern that this may be vital but may be overlooked if steps are not taken to make this a matter of routine”
3. absence of senior clinician at discharge case review
“am concerned at the lack of attendance of the Consultant [name redacted] or a suitably qualified and experienced junior colleague at the discharge case review/meeting. In a case of patient still on an ACCT and being discharged to an ordinary wing location without as senior clinician being able to attend and participate in the discharge case review , risk assessment at that stage and risk planning”
4. lack of graduated risk management plan
“| am concerned by the lack of planning or consideration of a graduated risk management plan in such circumstances. This was identified by the clinical reviewer. In other words increased frequency of day time interactions and throughout the whole day and MHIT and Psychiatrist contacts very shortly after the move”
5. insufficient safer cells for high-risk prisoners
“At the present time the HCC caters for some 22 patient prisoners and has 10 safer cells. | am concerned that the prison has a very limited number of safer cells on a limited number of other wings. At the present time there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures ). If prisoners are subject to ACCT's and either transferred from one wing to another or transferred from the HCC to an ordinary wing location ( for what ever reason”
6. lack of CCTV monitoring in high-risk cells
“In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly [name redacted] was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures. No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or”
Linked reports
Closely relatedConfidence 0.92 · high
This report
“The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr [name redacted] death.”
Later report
“(5) That all custody suites have sufficient facilities for CCTV monitoring of detainees at risk in custody whether held by the State or private custody providers.”
Closely relatedConfidence 0.80 · moderate
This report
“there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures )”
Later report
“'Normal' or 'standard' cells may not be best for cellular confinement, particularly for a prisoner placed on an ACCT”
Responses
No published response was found on judiciary.uk.