Michael Smith
10 Nov 2022 · Coroner Crispin Oliver · County Durham and Darlington
The coroner's concerns
1. lack of medical assessment while on 3 man unlock
“Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, [the deceased] was subject to a 3 man unlock”