CRAIG CHAPPELL · Prevention of Future Deaths report

On 8 August 2014 I commenced an investigation into the death of CRAIG CHAPPELL, AGED 35 YEARS. The investigation concluded at the end of the inquest on 2 SEPTEMBER 2015. The conclusion of the inquest was SUICIDE together with the following NARRATIVE - Based on the evidence provided we the Jury conclude Craig Chappell had reached a crisis point. A number of factors within his personal life together with some system failures at HMP Humber (Everthorpe Site) contributed to him taking his own life.

The medical cause of death was Ia Hanging II Alcohol and mixed drug intoxication

The deceased was found hanging in his cell at HMP Humber Everthorpe Site by staff at approximately 0630 hours on 8 August 2014. He had previously been subject to an ACCT document but this had been closed on 18 July 2014 having been open for some 24 hours or so only. Prior to his death he had been drinking Hooch which he had obtained in the prison and had taken prescription drugs. He suffered from depression issues which had been exacerbated by the recent death of his mother in December 2013, his own father's illness, he had suffered sexual abuse and had suffered constant pain in his leg following a below knee amputation. He had been receiving counselling in prison.

(1) There was no formal mechanism for communicating family concerns to relevant decision making professionals and inadequate information sharing.

(2) There was insufficient guidance given to prison staff on appropriate support for potential victims of abuse.

(3) There was on occasions some inappropriate reliance by non health care staff on the subject’s actual presentation and the subject’s own views without investigating this further.