Darren Barry WILLIAMS · Prevention of Future Deaths report

On 08/01/2019 I commenced an investigation into the death of Darren Barry WILLIAMS aged 39. The investigation concluded at the end of the inquest on 05/11/2019. The conclusion of the Jury at the inquest was: Suicide

Darren Williams was detained at HMP Woodhill from 2nd May 2018.

On 4th January on House Unit 1a in cell 1-12 at 15.49pm he was found hanging from a bed frame.

Based on the balance of probability the Jury find it more likely than not, that Darren took his own life and intended to do so.

In the circumstances leading up to the death of Darren Williams the Jury found that there was a consistent failure to follow due process and relevant protocols:
- ACCT procedures and protocols were not followed
- As an integral part of the ACCT process there was a significant failure to complete and allocate actions in Care Maps
- Rule 45 applications were not documented or correctly considered
- Information was not suitably shared between the effected departments

During Darren Williams time at HMP Woodhill the Jury have heard evidence that he refused to engage with some aspects of the support offered. However, the jury finds that the support provided was inadequate and lacking in key areas such as violence reduction, victim support, mental health and family engagement.

Given Darren Williams’ history of long term drug abuse and the accrual of debt whilst at HMP Woodhill it was vital these services were offered in full.

I have two concerns; firstly, it became apparent during the course of the evidence that ACCT reviews were being conducted on many occasions without someone from Healthcare being in attendance.

Secondly in this particular case there were four separate ACCT’s and it was apparent that not all relevant information available from previous ACCT’s was taken into consideration when a new ACCT was opened.