Todd James Salter · Prevention of Future Deaths report

On 4 October 2019 I commenced an investigation into the death of Todd James Salter. The investigation concluded at the end of the inquest . The conclusion of the inquest was:

Suicide

1a Suspension by ligature

Mr Salter was released from prison on licence in July 2019. Upon his release there was confusion regarding which organisation had responsibility to assist him with housing leading to him residing with his family. This had a deleterious effect on Mr Salter’s mental health as independent living was a key element of him being able to re-establish contact with his daughters. As time progressed Mr Salter’s struggles with life increased, the spice habit he had in prison combined with life challenges led to him taking illicit drugs. Although Mr Salter wished to overcome his drug habit and he and his family struggled to obtain support needed from the various agencies. Of note was that the Probation officer who had been assigned to Mr Salter stated in evidence that she did not know that an option available to her was to contact ASPIRE Drug and Alcohol Service for Doncaster. She further stated in evidence that she did not know that they could have referred Mr Salter for an assessment, could have sought advice from a Consultant psychiatrist and could have liaised with mental health services together with Mr Salter’s mother. These were all crucial elements in providing Mr Salter with the support he clearly needed. As it was, the Probation officer was exploring options to have Mr Salter recalled but communication with Mr Salter as to her intentions in this regard were far from clear. By the 30ᵗʰ September 2019 he was at crisis point, left his mother’s address, made his way to Doncaster police station where at some time between 02:41 a.m. and 07:15 a.m. on the 1ˢᵗ October 2019 Mr Salter hanged himself outside the police station.

(1) The lack of knowledge of the Probation officer as to the services she could contact to obtain necessary mental health assessments. This would appear at the very least to suggest this gap in knowledge may be due to inadequate training.

(2) Mr Salter being driven to desperate measures of committing criminal acts in an effort to be arrested or recalled in order to secure treatment and support; this appeared to be the way matters were moving forward without engaging with appropriate mental health services.

(3) Generally poor engagement and collaborative working with both agencies and family alike.