LEVI CRONIN · Prevention of Future Deaths report

At the conclusion of the inquest into the very sad death of LEVI CRONIN, the jury recorded a conclusion of ‘Suicide’ but also found that ‘there was a series of interconnected system inadequacies and failures which contributed to the death’, these being:

‘Insufficient recording of information. For example, inadequate recording of information in NOMIS and the Wing Observation Log such as recording of phone calls indicating welfare and other concerns.’;

‘Insufficient communication. For example, lack of information sharing between departments on Levi’s welfare.’;

‘Inadequate staffing levels, at the time, within mental health department and prison officer staff. For example, failure of offender supervisor to see Levi in a timely manner, failure to follow up within a timely manner after referral to mental health department and subsequent appointments.’; and

‘Inadequate support and supervision to the mental health department.’

Levi Cronin died in very tragic circumstances and was confirmed deceased at the West Suffolk Hospital having been taken there from HMP Highpoint where he was a serving prisoner and had been found hanging in the shower on his wing. Levi had a history of depression and self harm and had a number of current concerns in that he was worried about losing his flat, which was subject to a repossession order, had worries about his relationship and had received a letter from his girlfriend during the last week, and was anxious to obtain release on Home Detention Curfew so that he could continue a plumbing course he was very motivated to carry on with. Levi was not able to meet his offender supervisor to discuss this, due to apparent staff shortages, and it was also clear that there had been considerable staffing problems in respect of mental health staff as well as prison staff. On the day of his very sad death, as he had run out of credit, Levi was allowed to use an office telephone to speak to his girlfriend by an officer who remained present for what was clearly a difficult and emotional phone call. Sadly, Levi hung himself in the shower later that day.

During the inquest, concerns and questions arose about:

- The sharing of information between healthcare staff and prison staff, while accepting the importance of medical confidentiality and consent.

- The recording of ‘Static’ or ‘historical’ risk information (on a need to know basis) in a form that would make it more readily accessible to those at a later stage who might have to assess a changing situation and make a new dynamic risk assessment following a recent ‘trigger’ event

- The importance of ensuring that there is adequate and appropriate recording on prison wings of potentially significant event or observed changes in a person’s mood or behaviour that could, if all were taken together, assist staff in their very difficult task of making risk assessments in the complex and challenging environment of a busy prison.