“Evidence was heard in relation to Mr Clairmonte undertaking acts of self-harm whilst…”
Dated 26 Jun 2026, from the coroner for East Riding and Hull. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 17 Sep 2026, after the 56 days for replies had ended (21 Aug 2026). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated26 Jun 2026
- Deadline21 Aug 2026
- Published on judiciary.uk17 Sep 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Priory Group | Response publishedPublished on judiciary.uk in September 2026. |
| Care Quality Commission | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 17 Sep 2026, after the 56 days for replies had ended (21 Aug 2026). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
– (1) Evidence was heard in relation to Mr Clairmonte undertaking acts of self-harm whilst under constant supervision.in the psychiatric hospital, Stockton Hall. The purpose of the supervision was to prevent Mr Clairmonte from self-harming. To the extent that various incidents occurred, it is a concern that this was able to happen whilst being on constant observations. (2) Evidence was also heard that, contrary to NICE guidelines, the opportunity for HMP Full Sutton prison staff to visit Mr Clairmonte at Stockton Hall Psychiatric Hospital, prior to the transfer, was denied. HMP Full Sutton Custodial Managers attempted to visit Mr Clairmonte in order to allow him the opportunity to express any concerns about the transfer and for them to answer any questions. This was so in the context of Mr Clairmonte having been in the psychiatric hospital for six years. Mr Clairmonte was only given, by Stockton Hall, a notice period of three days of the fact of the transfer to a custodial environment.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0355
- Added to Minute Book
- 7 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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