Craig David Royce · Prevention of Future Deaths report

On 29 December 2016 I commenced an investigation into the death of Craig David Royce. The investigation concluded at the end of the inquest on 12 December 2017. The conclusion of the inquest was:

Craig David Royce died as a result of an accident whereby he committed a deliberate act which unexpectedly and unintentionally led to his death. We the jury believe Mr Royce’s risk of self-harm/suicide was not properly reviewed with appropriate precautions taken to manage the risk

Craig Royce, who was 46 years old at the time of his death, had a long history of mental health problems and he also suffered from epilepsy. On 15 August 2016 he was remanded in custody to HM Prison Chelmsford. On 26 October 2016 he was sentenced to 20 months imprisonment. During his time in custody he was subject to three ACCT processes and on the evening of 24 December 2016 he found hanging in his cell. The medical cause of death was 1a) Hypoxic brain injury b) Suspension. After an incident of self-harm on 16 October 2016 he was placed on the second of these ACCTs and a note within the documentation reads “refer to MH”. It would appear that no referral to the mental health service was made.

There is no form/template to deal with the situation of a prisoner who needs to be referred to the mental health service. Reliance upon the transfer of this vital information to Healthcare by means of a telephone conversation could be unreliable. A robust, simple documentary system is required for the communication of such important information, namely that a prisoner needs to be referred to mental health services for an assessment to be carried out by mental health services. This would be distinct from the TAG system which caters for a brief assessment to be relayed across.