DARREN WRIGHT · Prevention of Future Deaths report

On 11 November 2013 I commenced an investigation into the death of DARREN WRIGHT, AGE 35 YEARS. The investigation concluded at the end of the inquest on 21 January 2015. The conclusion of the inquest was medical cause of death: 1a) Hanging and conclusion: Mr Wright hanged himself. Contributory Factors: Inconsistencies with the sharing of and access to information across different departments within the Prison system.

Mr Wright was admitted to HMP Norwich on 4 September 2013 following an assault against a family member. It was his first time in prison. He was described by all members of staff and prisoners as “quiet” and “anxious”. During October 2 staff members raised concerns regarding his demeanour and he was assessed by mental health staff. He was not deemed at risk of self harm. No ACCT document was opened. He was found dead in his cell on 3 November 2013. Evidence was given that self harm risk assessments tools have been revised/put in place. Steps have been put in place to ensure communication between different staff is recorded so that other members of staff have access. Further training has been instigated regarding when opening an ACCT is appropriate and to ensure all members of staff are aware of procedures.

(1) On receiving Code Blue notification the Staff Nurse did not know where to go and had to call on her radio to be found and then taken to the cell;

(2) The Prison Officers attending Mr Wright had not had recent CPR training. It is understood that due to a lack of resources, CPR training has had to be allocated to certain members of staff only. This will result in gaps in CPR-trained Officers available and able to attend emergencies.