“are set out below”

The coroner’s concerns

This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.

are set out below. I have for ease of reference highlighted in bold type where a particular body or organisation is specifically referred to, and in brackets at the end of the entry, where the jury were silent but where I consider the body or organisation being referred to has responsibility to deal with it — 1. In the assessment of risk and risk management the jury found (inter alia) information provided by mental healthcare nursing staff to Prison Officers was not correctly documented. 2. There was inadequate communication between members of the Mental Health team as to the deceased’s condition and the level of risk of self-harm. S:\AGE PERSONAL\AGE Inquests\Hall.Inquest.Reg28.docx 3. There was inadequate communication between members of the Mental Health Team and the Healthcare Unit staff as to the deceased’s perceived condition and level of risk of self-harm. 4. There was inadequate communication between the Mental Health In Reach Team and the mental care unit staff as to the type and level of observation required when the deceased was re-admitted to the Healthcare Unit on 23 March 2009. 5. Insufficient attention was paid by healthcare professionals to the system | entries. 6. That both mental health staff and general nursing staff inadequately took into account the entry made by 7. That a post-closure interview in accordance with the (then) ACCT policy should have been conducted. ( Prison staff, healthcare staff and Mental Health team ) 8. Medication was not administered to the deceased on 23 March 2009 and 24 March 2009 as prescribed. ( Medical healthcare staff) 9. The deceased was not adequately observed between 6.30pm and 7.30pm on 27 March 2009. (Healthcare staff/Prison discipline officers) 10. The quality of CCTV images within the healthcare unit was inadequate. ( prison service) 11. Arrangements for staff members to use the CCTV screens were absent. (Prison service & Healthcare staff) 12. There was infrequent observation of the CCTV screens on 27 March 2009. (Prison service & Healthcare staff) 13. Generally the training and induction to visiting Psychiatrists in respect of the ACCT process was relevant to the circumstances in which the deceased died. 14. The practice of healthcare professionals regarding the reading of previous system 1 entries was also relevant to the circumstances in which the deceased died. 15. The awareness of prison policies in relation to the use of camera cells was also relevant to the circumstances in which the deceased died. (Prison service & Healthcare staff) 16. The training and instructions given to prison officers and nursing staff regarding use of and manipulation of the CCTV image was also “relevant” to the circumstances in which the deceased died. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and /or your organisation have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by [o” May 2014]. I, the coroner, may extend the period.

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, 2014-0122

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0