Stephen Shaylor
18 Dec 2017 · Coroner Elizabeth Earland · Exeter and Greater Devon
The coroner's concerns
1. insufficient stabilisation wing capacity
“There were 38 places available on a corridor in C4 wing as a stabilisation wing for dealing with inmates subject to Healthcare night welfare checks”
2. inadequate night welfare checks
“Professor Wall, substance misuse expert, said that the system for looking after these inmates was not fit for purpose and that healthcare night welfare checks (looking through a hatch in a cell door) were inadequate because it was not possible to ascertain if a prisoner was breathing/alive by this method”
3. intermittent night welfare checks
“Night welfare checks and observations on an ACCT document are at best intermittent and only continuous CCTV monitoring could spot a prisoner self-”