Russell Ian IRVINE · Prevention of Future Deaths report

On 10/11/2022 12:04am an investigation was commenced into the death of Russell Ian IRVINE 22/07/1971 00:00:00. The investigation concluded at the end of the inquest on 21/06/2024 14:36. The conclusion of the inquest was that Hanging - 7 November 2022 - HMP Durham, cell E3-03, Old Elvet, Durham, DH1 3HU.

See Attached:

We believe on the balance of probabilities that Mr Irvine had the intentions and took his own life on the evening of 7 November 2022 by hanging in his prison cell, ████████
████████

Mr Irvine also left a note in which he stated he was of sound mind.

Based on the evidence provided, the facts state that a number of policies and processes were not actioned or put I place correctly.

It is evident that Mr Irvine had previously documented risk factors for suicide and self-harm, however these factors were not identified by prison staff during the reception screening process.

It is evident that not all of the actions taken by healthcare were in compliance with the relevant policies.

It cannot be established on the evidence that these failings caused or contributed to Mr Irvine's death..

Hanging - 7 November 2022 - HMP Durham, cell E3-03, Old Elvet, Durham, DH1 3HU.

See Attached:

We believe on the balance of probabilities that Mr Irvine had the intentions and took his own life on the evening of 7 November 2022 by hanging in his prison cell, ████████
████████

Mr Irvine also left a note in which he stated he was of sound mind.

Based on the evidence provided, the facts state that a number of policies and processes were not actioned or put I place correctly.

It is evident that Mr Irvine had previously documented risk factors for suicide and self-harm, however these factors were not identified by prison staff during the reception screening process.

It is evident that not all of the actions taken by healthcare were in compliance with the relevant policies.

It cannot be established on the evidence that these failings caused or contributed to Mr Irvine's death..

Russell Ian Irvine died three days after his entry into HMP Durham on 4 November 2022 following his nicotine recall into custody, about which he protested and told reception healthcare staff that he had refused food and fluids for the previous two days. The evidence demonstrated that this information was not escalated in accordance with established policy which meant that Mr Irvine's food and fluid intake was not adequately or at all monitored by prison wing staff.

As to food and fluid monitoring generally and notwithstanding the availability of internal policies mandating necessary action in cases of known food and fluid refusal, evidence from prison officers at inquest was to the effect that no formal policy existed to monitor and identify whether a prisoner had collected their meal and so had necessary sustenance at least available to them.

The absence of such policy was identified by the Prison and Probation Ombudsman during its investigation as to the circumstances of Mr Irvine's death and this formed a recommendation within the Ombudsman's report. HMP Durham's response to this recommendation was the introduction of process and form to record instances when a prisoner failed to collect their meal as a means of monitoring their intake.

Evidence from a prisoner Governor was to the effect that she was not aware that such a process or form was in use at any other establishment within the nationwide secure estate, enquiries having been made to substantiate this. The concern is that other such establishments operate without the advantage of the safeguard now employed at HMP Durham with the risk of future deaths occurring elsewhere evident.