Craig Steadman · Prevention of Future Deaths report

On 7th March 2020 an investigation commenced into the death of Craig Steadman aged 32 years. The investigation concluded at the end of the inquest on 1st August 2024. The conclusion of the Jury at Inquest was Medical Cause of death 1a.Ligature Suspension and 2.Mental Illness

NARRATIVE CONCLUSION

Mr Steadman died by suicide at 01:25 on the 27/02/2022 in cell D36 at 3, West Hill, Romsey Road, Winchester. A probable contributing factor was the extended lock up due to the covid regime and staff shortages meaning that Mr Steadman had not left his cell at all on 26/02/2022. A possible contributing factor was the inadequate implementation of the ACCT process on 26/02/2022

In January 2020 Craig Steadman was released from Custody on Licence but a week later he breached a condition and was remanded back to HMP Winchester on 13th January. He had Diabetes and a mental health history, was on a weekly anti psychotic injection plus a history of multiple self harming incidents including overdosing on ████████

After being assessed as suitable to hold his own medication he overdosed on ████████ on 17th January 2020 and was placed on an ACCT which was closed again on 18th January.

He struggled with the Covid Lock Down restrictions and lack of contact with his family.

On 26th February he self harmed, cutting himself ████████ and the ACCT was reopened. At 00:44 he was found suspended by a ligature ████████ CPR by staff then paramedics proved futile and he was sadly pronounced deceased at 01:25 on 27th February 2020.

There were several investigations into Craig Steadman’s death including a post incident review by HMP Winchester, the PPO,and the prison healthcare provider.
Various recommendations flowed from the above.
However upon questioning of various members of staff called to give evidence at the Inquest it became clear that several of them were not aware of the findings of the investigations nor the recommendations. The reports had not been shared with staff directly involved with Craig during his recent time in custody.
It is not possible for learning to be fully disseminated and acted upon if there is no process for sharing the findings of those organisations tasked with investigating deaths in custody and discussing these with the relevant Prison/Healthcare staff.