Antony Richard COUGHTREY · Prevention of Future Deaths report

On 6th October 2015 I commenced an Investigation into the death of Antony Richard COUGHTREY aged 42 years. The Investigation concluded at the end of the Inquest on the 23rd of October 2017. The conclusion of the Inquest was that Antony Richard COUGHTREY died as a result of suicide but the Jury went on to find that there was a failure to manage his Licence adequately and this had caused or contributed to his death.

The medical cause of death was:
I (a) Hanging
I (b)
I (c)
II Chronic Pancreatitis

The circumstances of the death where that Antony COUGHTREY had been returned to prison for Breach of his Licence, having been released after serving 23 years of a life sentence when he had been charged with an assault upon his brother. Once back in prison he hanged himself.

1. that following a death of a prisoner who had been released on licence following a life sentence, there was no internal investigation by the Probation Service or any inquiry resembling a Serious Incident Review. They seem to have led to an air of complacency as to the Probation Service’s role in managing Mr Coughtrey

2. I also felt there was a failure in the procedure for referring a prisoner back to the Parole Board when there had been a clear breach of the Conditions of Licence set out by the Parole Board.