Robert Evans
18 Oct 2022 · Coroner Kirsten Heaven · Swansea and Neath Port Talbot
The coroner's concerns
1. self-inflicted deaths shortly after arrival
“there have been four self-inflicted deaths since the previous inspection, all within a week of arrival. This replicated findings at our previous inspection of Swansea”
2. vulnerable period during induction
“prisoners are not on the 2 induction unit for a significant period but that prisoners in the induction unit are in a vulnerable time in custody as they have just arrived in prison”
3. loss of critical witness statements
“these witnesses were the last members of prison staff [name redacted] spoke to before his death.”
4. evidence loss leading to repeat deaths
“if evidence relevant to a death in custody is not immediately captured and considered a situation may be created where evidence is lost which prevents general lessons from being learnt from a death in custody and that this creates a risk that other deaths will occur”