Lee Sean MACPHERSON · Prevention of Future Deaths report

On 22 October 2012 an inquest was opened into the death of Lee Sean MACPHERSON aged 46. The inquest concluded on 3 March 2014. The conclusion was that the medical cause of death was unascertained and the conclusion was open – the evidence did not fully or further disclose the means whereby the cause of death arose.

On 17 October 2012 the deceased was found dead in his cell, a safer custody cell, on the First Night Centre at HMP Wormwood Scrubs. He had been remanded into custody the afternoon before having been arrested on 15 October, held in police custody at Heathrow Police Station overnight, conveyed by SERCO to Uxbridge Magistrates’ Court and from there to prison. He had a longstanding history of paranoid schizophrenia which was partially treated by medication.

(1) The police risk assessment was not completed until the deceased had already been collected by SERCO and it was a police risk assessment completed in the early hours of the morning that found its way to the prison.
(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER. Boxes on the PER had been ticked indicating that, among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents.

(3) The escort handover details on the PER were not completed by the prison staff (or SERCO staff which is a matter SERCO have already addressed).

The PER and any accompanying risk assessment are of crucial importance when persons in custody are escorted from one place to another. Although these matters were not material to the outcome in this particular case it could well give rise to problems in the future.