Investigation and inquest
On 26 November 2019 I commenced an investigation into the death of Michael Richie DOBSON (‘Mike’). The investigation concluded at the end of the inquest on 9 February 2021. The conclusion of the inquest was suicide with the cause of death being hanging.
Circumstances of the death
Mike applied a ligature to himself using a piece of linen/sheet through a hole in the ceiling and hanged himself. This hanging occurred on 24.11.2019 at an approximate time between 19.00 and 19.25. Death was pronounced at Queen’s Hospital Bruton on 22.25 on 24.11.2019.
Probably causative factors: Mike had long standing poor mental health issues. There were also issues around illicit drug use. Mike had fractured family relationships. Mike had difficulties in establishing and engaging with relationships and the support offered to him.
Possibly causative factors: A lack of central base of information accessible to all relevant staff with useable information.
Coroner’s concerns
The hanging incident occurred after prison lockdown. Shortly prior to this the electricity supply for the sockets in the cell had tripped. Mike had used his cell bell to call a prison officer and he was told it would be sorted out but probably not until the next day. The inquest also heard that in some cases (not Mike’s) that cell lights will trip and this tends to take out four cells. It is also possible that other damage may be caused to cells. I am aware that there are very limited staff and security concerns following lockdown. If however prisoners become aware that remedial action may not take place until the following day this does provide a potential (either deliberate or accidental) for prisoners to harm themselves. I wonder if it is possible for some form of basic maintenance to be available during lockdown hours. If this concern appears more to be a national one rather than a local one then please feel free to pass it on to whoever it is appropriate to deal with it.