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Investigation and inquest
On 19 October 2021 I commenced an investigation into the death of Christopher Alistair MacGILLIVRAY. The investigation concluded at the end of the inquest . The jury reached the following conclusion:
Christopher MacGillivray hanged himself by a ligature whilst under the influence of a combination of Cocaine and alcohol.
1a Pressure on the neck
1b Hanging
1c
II
Circumstances of the death
Christopher Alistair MacGillivray had a long history of Drug and Alcohol issues and attempted suicide and self-harm complicated by the impact of a brain injury sustained in an assault in 2018.
He was charged with criminal offences for which he was granted conditional bail and subject to a curfew.
He was also managed by Probation Service under the terms of a Probation Order for an earlier offence.
On 9th October 2021 he was remanded in custody to HMP Durham for breach of his curfew. His arrest was precipitated by a member of the public who contacted police raising concerns for his welfare having seen him standing on the edge of a bridge.
On 10th October Christopher Alistair MacGillivray reported thoughts of self-harm to prison staff.
Suicide and self-harm prevention procedures known as ACCT (Assessment Care in Custody and Teamwork) were implemented.
He was placed on hourly observations.
On 12th October Christopher Alistair MacGillivray was released on bail by Magistrates following a hearing via remote link. The ACCT was then closed.
There was no direct communication from Prison to his Probation Officer/Manager in respect of his release and his risk of self-harm.
On 14th October Christopher Alistair MacGillivray was found hanging in his home where his death was confirmed.
Coroner’s concerns
(1) The prison service instruction (PSI) 64/2011 sets out the procedures that must be followed to manage prisoner safety. The Annex sets out a mandatory process for the planned release of a prisoner who has been on an ACCT.
Offender Management in Custody (OMiC) guidance provides for direct communication between Prison Offender Manager and Community Offender Manager in respect of prisoners at risk of self harm for SENTENCED PRISONERS ONLY.
(2) The PSI is silent in respect of unplanned releases for 'prisoners on remand' with a known risk of self-harm and who may be released at short notice.
There is no apparent direction/mandatory procedure for communication of the known risk of self-harm for unplanned release.
(3) There is a risk of future deaths of prisoners in the category as at para 2 above. Urgent amendment to PSI/Annex and OMiC is required to set out procedures that must be followed in the management of the unplanned release of prisoners at risk of self-harm/suicide.
Information checked against the published report and official responses