James Devenny
25 May 2021 · Coroner Ian Brownhill · Mid Kent and Medway
The coroner's concerns
1. lack of direct telephone access for prisoners to contact Samaritans
“In the absence of telephones which are installed directly into the cell, there is no direct means for a prisoner to contact the Samaritans. In the event that a prisoner does not have access to a telephone they are reliant on staff to convey them to a telephone so they may call. There is a particular difficulty in respect of prisoners who are deemed to pose a risk of violence and who may not be able to immediately access a telephone, a listener or a member of Chaplaincy”
2. lack of routine briefing on prisoners' history of significant self-harm
“Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed save that they will be informed if a prisoner arrives with an open ACCT. Prison Officers are not routinely briefed as to a prisoner's previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm”
3. staff unaware of prisoner's prior self-harm history
“Staff on houseblock 2 at HMP Elmley were not aware of information as to his history of self-harm which occurred before he arrived there”
4. lack of medical assessment for segregation suitability
“Following the decision to keep Mr [name redacted] separated from other prisoners, there was not an assessment by a medical professional as to whether he was fit to be separated”
5. inappropriate mental health team response to referrals
“The response of the mental health in reach team to referrals in respect of Mr [name redacted] was not appropriate”