Stewart Stanley · Prevention of Future Deaths report

On 15 July 2020 an investigation was commenced into the death of Stewart Stanley. The investigation concluded at the end of the inquest held on 17 -27 July 2023. The conclusion of the inquest was Suicide in addition the Jury answered a series of questions raised by me.

In summary, the Jury concluded that Mr Stanley’s death was probably caused or contributed to by a failure to follow the processes resulting in the staff best qualified to appreciate Stewart’s risk to himself being excluded from the decision to remove him from constant watch. In the addition the Jury concluded that the multi-disciplinary processes in place were adequate however they were not fully complied with in this case.

On 23 June 2020 Mr Stanley was remanded in custody to HMP Exeter.

On the night of 9 to 10 July, Mr Stanley’s cellmate found him ████████ seemingly trying to hang himself. He alerted prison staff, who started Prison Service suicide and self-harm prevention procedures (known as ACCT). The staff placed Mr Stanley under constant supervision and moved him to a special cell that allowed an officer to observe him continuously. On 11 July, after a case review it was decided that constant supervision should end and directed that Mr Stanley should now be observed at least once every half an hour during the evening. At around 1.20am on 12 July, the night patrol officer, found Mr Stanley hanging. She called for staff assistance and, when it arrived, they opened the cell, removed the ligature and began chest compressions. Paramedics arrived and took Mr Stanley to hospital, where he died on 14 July.

(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording observations on prisoners subject to the Prison Service suicide and self-harm prevention procedures (known as ACCT).
(2) The evidence also revealed that some Officers had a different interpretation of the requirements of set out in PSI 64/2011 in respect of the timing of observations.
(3) The evidence also revealed that precise times of such observations were not routinely being recorded accurately.
(4) During the evidence it became apparent that a prison officer worked 23 hours out of 24, he was asked if this was normal and he replied, “yes, to make the regime work.”