Michael Williams · Prevention of Future Deaths report

On 17th September 2015 I commenced an investigation into the death of Michael Williams. The inquest concluded on 7th July 2016.

The jury made the following findings -

The jury concluded the death was suicide.

On 15th September 2015 between 21.45 and 22.45 Mr Williams died by hanging in his cell at 116 Ward Road. Although low traces of Mamba were found in his bloodstream, the influence of it on Mr Williams capacity to take his own life cannot be determined. At the time of his death Mr Williams was on 4 observations per hour. Mr Williams was last seen at 21.30 and was heard after this time. During these last two hours Mr Williams, on more than one occasion blocked the observation panel and inundation point of his cell door and wrote 2 suicide notes, 1 of which was ingested, and a note on cell wall. Access to the cell was at 22.45 an inappropriate delay. The prison officers found Mr Williams hanging from the window bars by a ligature around his neck made from a torn bedsheet. Mr Williams was pronounced dead on 16th September 2015 at the Leicester Royal Infirmary.

Cause of Death
1a Hanging

Mr Williams took his own life by use of a ligature, while in a single occupancy locked cell. At the time he was on an ACCT document, and had threatened to take his life earlier that day; had presented as tearful and anxious; had disengaged with prison officers; had covered his observation panel with both layers of paper and a bed sheet and the required 4 observations per hour had not been adhered to.

Mr Williams should have been observed 4x every hour during the evening of 15th September 2015. Several of these checks were missed, and after he blocked the observation panel, he could only be heard, not seen.

a) Observations (where they were carried out) were documented at precise 15 minute intervals, commencing on the hour, and were therefore predictable. This is not best practice and should be discouraged.
b) There was no explanation for the missed observations.
c) Mr Williams was unobserved for approximately 1 hour before the cell door was opened, and he was found deceased. The jury found this was inappropriate delay and I agree with them. Clear guidance and training should be provided, and regularly repeated, to assist the Prison Officers in managing such situations in a timely way.