Marcin Stoga
21 Jul 2014 · Coroner Darren Salter · Oxfordshire
The coroner's concerns
1. information not available to staff during initial assessment
“Prior to Mr [name redacted] arrival at HMP Bullingdon, there was a Prisoner Escort Record which referred to the fact that Mr [name redacted] had taken an overdose in 2012. It appears that | this form and this information was not available to the Prison Officers or the Healthcare Nurse who initially assessed Mr [name redacted] upon his arrival”
2. lack of routine post-court assessment for high-risk prisoners
“prisoners (particularly those with mental health difficulties or who are otherwise at a medium/high risk of self-harm) are not routinely assessed on return from court hearings”
3. cursory post-court assessments may miss critical changes
“there has been a review (and that this issue also formed part of the PPO Recommendations) and that persons returning from court will be seen by the Duty Reception Nurse to ascertain any change in circumstances”