PAUL DAVID ANTHONY JAMES · Prevention of Future Deaths report

The inquest into the death of Mr James was opened and adjourned on 23/12/16. It was resumed on 9/4/18 and concluded on 18/4/18.

The cause of death was 1a Incised Wound to Abdomen. The conclusion of the jury was death by misadventure. In a discrete question asked of the jury the conclusion was that it had been unreasonable to allow Mr James access to razor blades in his cell.

Mr James was arrested in Gillingham on 24/4/16 for criminal damage. He was taken to Medway Maritime Hospital as a result of extensive injuries to his left arm due to self harm. When taken into custody at Medway Police Station he told the custody sergeant that on this occasion he had intentionally self harmed and that he had also tried to harm himself on previous occasions whilst under the influence of drink or drugs.

He was initially remanded in custody at HMP Belmarsh. On 30/6/16 he was sentenced to 2 years and 2 months imprisonment for offences of affray and the breach of a suspended sentence for assault occasioning actual bodily harm. He was received into HMP Elmley on 31/5/16.

On 5/7/16 an ACCT (assessment, care in custody and teamwork report) was opened after Mr James stated that he wanted to take his own life.

On 8/7/16 Mr James was in a three person cell. He cut his arms and thighs . The room was covered in blood. Staff then saw Mr James cut his right forearm and pull out his own organs; fat, vessels and ligaments could be seen. He would not stop. He then found another razor blade and cut his inner thighs. Officers put on full protective clothing and after entering the cell subdued Mr James. Senior Officer Cunningham described it as the worst self harm he had ever seen. An ambulance and an air ambulance were summoned and Mr James was taken to King’s College Hospital where he was placed in an induced coma.

Mr James returned to HMP Elmley on 13/7/16. Between that date and the date of his death, 20/12/16, he was the subject of considerable attention from prison health care. That included assistance in the inpatients department, once for some considerable time and specialist care from two consultant psychiatrists. In the latter stages it became clear that he was not taking the drugs prescribed to him.

On 20/12/16 Mr James was found in his cell at 09.50 am having made tentative cuts to his abdomen with a razor blade. He had then made a 17 cm long cut to his abdomen to a depth of approximately 3 cm. Officers, a nurse and a doctor attended but it was clear to them that Mr James had died some time earlier. He was certified dead at 10.03 am.

That Mr James was given access to razor blades in all the circumstances.