Kirk Duboise · Prevention of Future Deaths report

On 3rd December 2013 I commenced an investigation into the death of Kirk Duboise. The investigation concluded at the end of the inquest on 5th December 2013. The conclusion of the inquest was Mr Duboise was found dead in his cell at HMP Durham on 13/2/13 and a narrative conclusion was returned “The deceased intentionally took his own life. The deceased was not correctly assessed at HMP Durham. An ACCT should have been opened at reception by prison staff.”

The deceased arrived at HMP Durham when there was with him a prisoner escort report form highlighting self harm issues and also a suicide/self harm warning form again highlighting self harm issues. The deceased had clear self harm marks on his arms. Prison and health care staff at reception did not see both of these documents and did not open an ACCT. Mr Duboise committed suicide in his cell approximately 8 hours after arriving at HMP Durham. No other member of staff opened at ACCT in the intervening period. The Jury concluded that an ACCT ought to have been opened at reception by prison staff. Notwithstanding training which states that an ACCT can be opened by any member of staff at any time the practice of at least one senior officer at reception was that he would not open an ACCT unless at reception the incoming prisoner was subject to constant watch observations. This practice was confirmed by an experienced mental health nurse who saw the deceased as part of the reception process. Evidence was given that the reception process has, since the deceased’s death in February 2013, been changed.

A prison governor confirmed that the correct code words had not been used when the deceased was found hanging in his cell which resulted in their being a delay before an ambulance was summoned.

(1) The delay in summoning an ambulance.
(2) That not all relevant forms were seen by those involved in the reception process one of whose duties at such time was to properly assess the risk of self harm of the new prisoner, particularly a prisoner who had not been in custody before.