Yohannes Kidane · Prevention of Future Deaths report

On 15 January 2014 I commenced an investigation into the death of Yohannes Kidane. The investigation concluded at the end of the inquest on 3 September 2014.
The conclusion of the inquest was the deceased died from 1a. Asphyxia due to 1b. Low level suspension/compression of the neck and the jury recorded a conclusion of suicide.

Mr Kidane was remanded into custody on 10/12/13 at Birmingham Prison. On 11/12/13 he tried to electrocute himself with a kettle cable and was placed on an ACCT. He was assessed on 12/12/13 and admitted to ward 2 of the healthcare department. On 18/12/13 he smashed his TV and made superficial cuts to his arms and abdomen. On the evening of 19/12/13 he lay on the floor between the window and the bed. He could not be seen from the cell hatch. At 22.53 he was found with a noose around his neck attached via his back to his ankle. This mechanism had been used to self-asphyxiate. CPR was provided but he was declared dead in his cell at 23.20 by paramedics.

(1) The healthcare department has 2 wards with 15 patients on each ward. The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards. Evidence confirmed there were a number of prisoners on ward 2 who required ACCT observation plus other prisoners requiring attention. At the time only 1 nurse was present as the Prison officer was on the other ward.
I am concerned the wards have insufficient staff at night to provide for all the healthcare and other needs of prisoners.
(2) I am concerned that the ability to undertake effective ACCT observations is compromised by the lack of sufficient staff.
(3) When I asked how staff took breaks at night I was told staff did not take breaks during the night. I am concerned about the impact this would have on the care and wellbeing of prisoners and on the staff. Staff must need to take comfort breaks throughout the night which would add an additional burden on the already stretched staffing levels.