Vilhelmas Borkertas
31 Oct 2017 · Coroner ME Hassell · London Inner (North)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. delayed staff response to cell bell
“I gave a great deal of consideration at inquest to the exploration of the time it took staff to attend to Mr [name redacted] after his cellmate rang the cell bell. However, I do not write about that now because I know that it is a matter already under scrutiny by the prison, and I do not think there is anything that I can helpfully add.”
2. inappropriate cell sharing of individuals with conflicting sexual orientation risk
“Mr [name redacted] described himself variously as heterosexual and bisexual. The latter was recorded on his cell sharing risk assessment form. His cellmate at the time of death described himself as being homophobic. This was recorded on his cell sharing risk assessment form. However, the two were placed together in a cell and I heard no evidence that consideration was ever given to the potential dangers of this.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“The nurse who carried out the first reception screen of Mr [name redacted] did not complete a cell sharing risk assessment (CSRA)”
This report
“Mr [name redacted] described himself variously as heterosexual and bisexual. The latter was recorded on his cell sharing risk assessment form.”
Responses
No published response was found on judiciary.uk.