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Investigation and inquest
On 13 March 2013 I commenced an investigation into the death of John Derek Stabler, aged 55 years. The investigation concluded at the end of the inquest on 17 October 2014 - The Jury returned a conclusion that 'He killed himself' The medical cause of death being :
1a. Hanging
Circumstances of the death
At 0100 hours on 4 March 2013 the deceased was found hanging in cell D1.5 in HMP Lincoln. He was taken to Lincoln County Hospital where he died on 6 March 2013.
He was serving an indeterminate sentence, was an inmate at HMP North Sea Camp where he had a history of mental health problems. He was transferred to HMP Lincoln on 1 March 2013 and was found hanging (though not deceased) in a cell on the Segregation Wing on 4 March 2013. He was taken to Lincoln County Hospital where he died on 6 March 2013.
Coroner’s concerns
(i) That there is a need for the Prisoner Escort Record to be reviewed and redesigned
(II) The requirements for System 1 (Medical Records) to be made available in Reception at HMP North Sea Camp and in The Care and Reception Unit at HMP Lincoln
Information checked against the published report and official responses