Stuart Baumber

1. 1. ligature points in cell doors

   “The deceased was a design engineer and his sketches found after death in his cell set out diagrammatically how he deduced that the gap between the cell door and frame would allow a ligature to be threaded through and that a wedge could be created with paper pamphlets to prevent slippage of the ligature”

2. 2. ligature points in cell doors

   “The risk of cell doors being used for ligature points is well known”

3. 3. ligature points in cells

   “The need to eradicate ligature points in cells has been the subject of recommendations in PPO reports in Northern Ireland (JOHN MARTIN GERARD KENNEWAY published 10.12 2009 at recommendation 10 and COLIN MARTIN BELL published 9.1.2009 at recommendation 9) and many Australian Coronial decisions and observations of Coroners in England and Wales in the old Rule 43 and the new Regulation 28 reports”

4. 4. ligature points in cells

   “Further, this was the subject of detailed commentary in the paper produced by the [name redacted] of Crime Science (University College London) where it was recognised as being of paramount importance that there be removal of as many ligature points as possible in cells and that remedial action would need to be taken as quickly as possible before a new method spreads within and between establishments”

5. 5. lack of retrofit of anti-ligature strips

   “Evidence was given that the cost of a national retrofit programme for all doors being adapted with an anti-ligature strip to meet the new design would be a significant proportion of the current budget”

6. 6. lack of documentation of concerns

   “The solicitor for the deceased telephoned the prison on one occasion to express concern about him but no record could be produced of this or action taken”

No published response was found on judiciary.uk.