David Clairmonte: Prevention of future deaths report (2)

“Evidence was heard in relation to Mr [name redacted] undertaking acts of self-harm whilst under constant supervision.in the psychiatric hospital, Stockton Hall. The purpose of the supervision was to prevent Mr [name redacted] from self-harming. To the extent that various incidents occurred, it is a concern that this was able to happen whilst being on constant observations.”

“Evidence was also heard that, contrary to NICE guidelines, the opportunity for HMP Full Sutton prison staff to visit Mr [name redacted] at Stockton Hall Psychiatric Hospital, prior to the transfer, was denied. HMP Full Sutton Custodial Managers attempted to visit Mr [name redacted] in order to allow him the opportunity to express any concerns about the transfer and for them to answer any questions. This was so in the context of Mr [name redacted] having been in the psychiatric hospital for six years. Mr [name redacted] was only given, by Stockton Hall, a notice period of three days of the fact of the transfer to a custodial environment.”