Andrew Ronald Hall · Prevention of Future Deaths report

On 31 March 2009 I commenced an investigation into the death of Andrew Ronald Hall aged 41 years (date of birth 6 June 1967). The investigation concluded at the end of the inquest on 13 June 2013. The conclusion of the inquest was that Andrew Ronald Hall killed himself while the balance of his mind was disturbed and the cause of death was contributed to by negligent. The jury also recorded their findings in a narrative form for a ████████

Between 19.20 hours and 19.35 hours on 27 March 2009 in cell 5 of Health Care Unit at HM Holme House Prison the deceased caused incised wounds to his neck causing hypovolaemic shock which caused his death. On the said date the deceased was an inmate detained lawfully at Her Majesty’s Prison Holme House.

1. In the assessment of risk and risk management the jury found (inter alia) information provided by mental healthcare nursing staff to Prison Officers was not correctly documented.

2. There was inadequate communication between members of the Mental Health team as to the deceased’s condition and the level of risk of self-harm.

3. There was inadequate communication between members of the Mental Health Team and the Healthcare Unit staff as to the deceased’s perceived condition and level of risk of self-harm.

4. There was inadequate communication between the Mental Health In Reach Team and the mental care unit staff as to the type and level of observation required when the deceased was re-admitted to the Healthcare Unit on 23 March 2009.

5. Insufficient attention was paid by healthcare professionals to the system 1 entries.

6. That both mental health staff and general nursing staff inadequately took into account the entry made by ████████

7. That a post-closure interview in accordance with the (then) ACCT policy should have been conducted. (Prison staff, healthcare staff and Mental Health team)

8. Medication was not administered to the deceased on 23 March 2009 and 24 March 2009 as prescribed. (Medical healthcare staff)

9. The deceased was not adequately observed between 6.30pm and 7.30pm on 27 March 2009. (Healthcare staff/Prison discipline officers)

10. The quality of CCTV images within the healthcare unit was inadequate. ( prison service)

11. Arrangements for staff members to use the CCTV screens were absent. (Prison service & Healthcare staff)

12. There was infrequent observation of the CCTV screens on 27 March 2009. (Prison service & Healthcare staff)

13. Generally the training and induction to visiting Psychiatrists in respect of the ACCT process was relevant to the circumstances in which the deceased died.

14. The practice of healthcare professionals regarding the reading of previous system 1 entries was also relevant to the circumstances in which the deceased died.

15. The awareness of prison policies in relation to the use of camera cells was also relevant to the circumstances in which the deceased died. (Prison service & Healthcare staff)

16. The training and instructions given to prison officers and nursing staff regarding use of and manipulation of the CCTV image was also “relevant” to the circumstances in which the deceased died.