Carl Lee Walters · Prevention of Future Deaths report

On 14th July 2021 I commenced an inquest into the death of Carl Lee Walters aged 34. The investigation concluded at the end of the inquest on 21st July 2021. The conclusion of the inquest was that Mr Walters died as a result of intraperitoneal haemorrhage due to a ruptured splenic pseudoaneurysm of undetermined aetiology, the evidence not revealing whether this was naturally occurring or trauma related and if the latter whether the trauma arose out of an accidental blunt force impact or an assault.

Mr Walters died suddenly and unexpectedly in his cell. The cause of his death was a ruptured splenic pseudoaneurysm which was most likely to have been trauma related. Although there was no evidence to the effect that Mr Walters had been injured whilst he was in prison the possibility nevertheless existed. As such it was very important that prison CCTV footage should be examined. Further, Mr Walters’ cellmate alleged that he had pressed the emergency cell bell on numerous occasions. However, despite the provisions of Chapter 12 of PSI 64/2011 CCTV images had not been preserved and only limited cell bell records had been kept.

The failure to preserve key evidence meant that the inquest could not be as full as it would otherwise have been. If key evidence is not preserved there is an ongoing risk that dangerous conditions or circumstances go undiscovered raising the prospect that appropriate steps to avoid a similar tragedy are overlooked.