Investigation and inquest
On 4th February 2015 an investigation was commenced into the death of Mark Anthony Holdsworth, aged 35 years at the time of his death. The investigation concluded at the Inquest on the 10th December 2015. I returned a conclusion of 'Took his life'. The medical cause of death was:
1a. Multiple Injuries
Circumstances of the death
The deceased was released from Police Custody at Lincoln Police station at 00.26 hrs on 23/01/2015 following an allegation under the Sexual Offences Act 2003. He was collected by a family member and taken to his car as he wished to have a drive around. At 04.37 hrs the same morning he was laid on the train line between Lincoln and Doncaster when he was struck by a freight train. The death was confirmed by attending paramedics.
Coroner’s concerns
Mark Anthony Holdsworth was arrested by the Police on 23rd January 2015 on suspicion of rape of his 14 year old step daughter ████████ He committed suicide in the early hours on 24th January 2015 shortly after being released from custody on police bail.
Shortly prior to his arrest, other officers took the complainant and her mother to Spring Lodge for an ABE/WVI interview. On route, ████████ Mother ████████ told the officers that Mr Holdsworth had said he would 'kill himself if released' This information was, I am told, later added to the incident log but was not drawn to the attention of either the arresting officers or the custody staff or Custody Sergeant.
There is not criticism of the risk assessment procedure undertaken by the custody staff when Mr Holdsworth was booked in at Lincoln station but it's clear that they lacked the significant information that Mr Holdsworth had very recently threatened to kill himself.
I am not sure what time the incident log was updated (I have not seen it) but I appreciate that it is impracticable to suggest that custody staff examine incident logs regularly because of the pressure of time and work.