John Wright
21 Mar 2019 · Coroner Darren Salter · Oxfordshire
The coroner's concerns
1. information about heightened suicide risk not reaching reception staff
“The first concern which | raise applies to both the prison and healthcare and relates to the receipt of information by the prison and/or healthcare about a heightened risk of self-harm/suicide for a prisoner who has yet to arrive at prison”
2. premature reduction of observation level
“Mr [name redacted] had been on constant watch, but a decision was taken during the reception process to step down to twice hourly observations”