Investigation and inquest
On 26 February 2021 I commenced an investigation into the death of Carl Shaun Langdell, aged 31. The investigation concluded at the end of the Inquest on 21 October 2022. The conclusion of the Inquest was a narrative recording that death was attributable to haemorrhage from neck incision, and made findings in relation to Mr Langdell’s management by the prison authorities and healthcare provider, along with a finding of suicide.
Circumstances of the death
On 11 February 2021 around 00.05 Carl Shaun Langdell was discovered in his locked, single occupancy cell with a significant wound to his neck. He was still able to speak ████████ Despite emergency treatment he went into cardiac arrest. He was certified dead at 01:47 on Thursday 11 February 2021 at Pinderfields Hospital, Wakefield.
Coroner’s concerns
(1) ████████
(2) He had been identified by a consultant psychiatrist as at “chronic risk of suicide attempts/self-harm attempts which is likely to remain due to the nature of his personality disorder”.
(3) In January 2021 he was observed to be acting in a bizarre and agitated manner after refusing his prescribed medication for the previous month.
(4) Despite this history and the known risk he was permitted under the prevailing ████████ rules at HMP Wakefield to be in possession of ████████ when alone in his locked cell overnight.
(5) ████████
(6) ████████
(7) Evidence was taken at the inquest from a Governor who indicated a national proposal had been made ████████. If implemented this plan would remove one obvious risk.