Robert Scott McLoughlin · Prevention of Future Deaths report

On the 26th February 2016 I commenced an Investigation into the death of Robert Scott McLoughlin, aged 32. The Investigation concluded at the end of the Inquest on 12th October 2018. The conclusion of the Inquest was Misadventure. The medical cause of death was 1(a) Hypoxic brain injury, 1(b) Hanging, (2) Bronchopneumonia.

At the time of his death the deceased was an inmate at HMP Leeds. He arrived on the 15th February 2016. Upon arrival an ACCT was opened. On the 20th February 2016 he was found suspended by a ligature. He was taken to The General Infirmary, Great George Street, Leeds where notwithstanding treatment he died on the 25th February 2016. The Jury found that there were errors or omissions in respect of his various aspects of his care. The Jury were of the view that it was possible that the death would have been prevented had these errors or omissions not occurred.

(1) The staffing levels at HMP Leeds were very low. On the evening of the 19th February 2016 when Mr McLoughlin self-harmed there was one Officer Support Grade on his wing. In addition there were only six Prison Officers on the night shift. On the morning of the 20th February 2016 the staffing levels were such that there was no Landing Officer on Mr McLoughlin’s landing. As a result ACCT reviews did not take place between approximately 0730 hours and 1340 hours.