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Investigation and inquest
On 30th October 2018 I commenced an investigation into the death of Trevor Albert Oakley, who was 74 years old. The investigation concluded at the end of the inquest on 23rd October 2019. The conclusion of the inquest was that Mr Oakley’s death was due to suicide, with a medical cause of death as: 1a. Ligature suspension.
Circumstances of the death
At 06:26 hours on the Twenty-second of October 2018 Trevor Albert Oakley was found hanging from the window bars in his cell. He had suspended himself from a ligature made of a bedsheet. He was hidden behind a non-prison issue ‘privacy curtain’. He was pronounced deceased at 06:50am by attending paramedics. Mr Oakley was due to start his Trial at Salisbury Crown Court that morning (the 22nd October 2018) for serious sexual offences.
Mr Oakley was remanded to HMP Winchester on the 14th February 2018. Prior to his remand he had taken an intentional overdose of insulin and prescription medication on the 28th January 2018; being the day that officers from Hampshire Police had attended to arrest him on suspicion of committing the sexual offences for which he was ultimately due to stand trial. He was hospitalised for 8 days and on discharge from hospital was admitted to a psychiatric ward. On discharge from the psychiatric ward he was arrested and on appearing before Basingstoke Magistrates Court on the 14th February 2018 he was remanded into custody.
Mr Oakley had three ACCTs opened whilst he was in prison; the last of which was opened on the 8th August 2018 and closed the following day, namely the 9th August2019. This related to issues of alleged bullying of Mr Oakley by his cellmate. Between August and the date of his death there was no involvement of mental health.
On the 22nd October 2018 Mr Oakley was due to start his trial. I heard evidence that he would have been aware of this date, most likely via his legal representative, and the trial would have been the first time he would have faced his family since they had made serious allegations against him for sexual assault (of his daughters and grandchildren). I heard evidence from witnesses within the Health Service at the Prison that Mr Oakley had a pattern of being unwell on the occasions when he was due to attend Court and so the start of his trial is likely to have been a stressful time for him.
Coroner’s concerns
(1) I was told that the Courts will supply the Prison with a list of prisoners who are required for trial the following day, (“the List”). The List is circulated within the prison by the OMU (Offender Management Unit) and the relevant staff should receive the List to enable them to know which particular prisoners need to be unlocked for Court attendances the following day. I was told that the Night Orderly Officer will brief the night shift officers on the wings as to what is due to be happening over the course of the night shift, but it was the evidence of more than one Prison Officer on duty that there was no notification of the prisoners due in Court the next morning. The stance adopted within the prison appeared to be that the information was available if a Prison Officer wanted to go and look for it within the system.
(2) I am concerned that within the Prison it is not immediately apparent to the night staff who is due in Court the following morning from this, it flows, that any increased risk of self-harm by such prisoner(s) is not identified.
Information checked against the published report and official responses