Damion Anthony Andre Martin · Prevention of Future Deaths report

On 13/12/2011 Mr Andre Rebello, HM Coroner for Liverpool, opened the inquest into the death of Damion Anthony Andre Martin, who at the date his death was 36 years old. The inquest was resumed and concluded on 23/10/2013 before a jury.

The jury found the cause of death to be:

1a – Hanging

The jury concluded by finding that Damion Anthony Andre Martin took his own life.

Liverpool Magistrates remanded Damion Anthony Andre Martin in custody to HMP Liverpool on 6/12/11 for alleged offences of Common Assault and Witness Intimidation against his partner ████████. Upon transfer to the prison, Mr Martin undertook initial reception and medical examination and cell share risk assessment, where it was identified that he was a first time prisoner, before being placed in cell 5, landing 4 on G wing with cell ████████. Mr Martin’s cell was visited several times during the role check at approximately 5.15am 11/12/11 by a prison officer. A prison officer did not further visit Mr Martin’s cell during the subsequent roll check at 6.15am. Subsequently at 8.25am Mr Martin was found hanging in the w.c. area of cell 5 from a ligature made from bedding attached to the air vent above the window. Although he was cut down attempts to resuscitate him were unsuccessful and he was found to have died.

• During the initial prison reception and risk assessment, the domestic nature of Mr Martin’s alleged charges of Common Assault and Witness Intimidation against his girl friend were not identified, notwithstanding it was considered to be a known suicidal risk factor.
• The first prison officer to respond to Mr Martin did not commence CPR sine he felt out of date with his first aid. This raised concerns that there is no refresher training or a cycle of refresher training in basic life support.
• The observation window to the w.c. area of cell 5 had a restricted view which did not extend to the area of the w.c. Mr Martin was found hanging.
• Notwithstanding documentation to the contrary, a prison officer upon his roll check at approximately 5.15am did not visit Mr Martin’s cell.

I would ask that you give consideration to these above concerns.