Peter Harry Mackie · Prevention of Future Deaths report

On 03/01/2014 I commenced an investigation into the death of Peter Harry Mackie, 42 . The investigation concluded at the end of inquest held from 24th November to 1st December 2014. The Conclusion was that “ He took his own life, whilst the balance of his mind was disturbed. Between 14:51 and 15:08 on Saturday 28th December 2013, the deceased hanged himself in the chapel at HMP Springhill. ”

At about 1545 hours on Saturday 28th December 2013 Police received a call from staff at the prison to say that a male was hanging (deceased) in the chapel. An air ambulance had been called and he had been declared life extinct at 1536 hours by ████████. The circumstances around Peter MACKIE – He was currently at Springhill Prison serving a life sentence for possession of an imitation firearm and robbery in 2001. He had been there for about 4 months after being at different category prisons. After lunch on the 28th December Mr Mackie went and spoke to another inmate outside his hut. Mr MACKIE asked him to go to the chapel and the other inmate thought he looked upset .They walked over to the centre and asked prison staff to let them into the main building where the chapel was located. At the same time another inmate came over and went into the chapel with them .The first inmate recalls that Mr MACKIE stated that he was upset, he mentioned that it was the anniversary of his mother’s death (1 year) and he had never been told about the funeral therefore he never went. He also mentioned that he owed money but this has not been confirmed. They remained within the chapel for about an hour and the second inmate was looking through the Bible and reading out verses to try and help Mr MACKIE .The first inmate thought that after that hour Mr MACKIE was a lot better. He also mentioned that he thought Mr MACKIE was dressed very smartly as if he was in his best clothes. They all left and the first inmate recalls Mr MACKIE asking him to return to the chapel in about half an hour's time. He thought that Mr MACKIE was ok and had other things to do so forgot to go back .At around 1500 hours a third inmate returned to the prison after having leave over the Christmas period. From reception he went straight to the chapel as he spends a lot of time there due to his religious beliefs. He went straight through the unlocked door, up the stairs and then saw a male hanging. Initially he thought it was a prank as he had never seen anything like it before. He then approached Mr MACKIE to get him down and realised that he could not therefore he ran back to the reception and told 2 prison staff .All three ran to the chapel. One of the officers held the legs and the prisoner used a “ fishknife” to cut Mr MACKIE down. No CPR was performed.

(1) Despite improvements during 2014 concerns remain as to the overall numbers of first aiders available on the Springhill site at any time including at night. A first aider on the Grendon site is unlikely to be able to respond in time due necessary security moving from a closed estate to an open prison. This applies in respect of those trained to “First aid at work (FAW) and Emergency First aid at work (EFAW). Operational needs may deplete numbers with FAW and/or EFAW by transferring them to the closed part of the overall site.

(2)There are usually two contracted healthcare staff available during daytimes but they work together and are therefore either on one site or the other. Staff are inevitably security delays in moving between the two prisons and the possibility of splitting this cover was raised in the evidence.

(3)It appears that there is not currently any guidance to staff as to when CPR should be commenced. This applies to CPR trained staff. For those without such training there is a lack of clarity as to what if any action they should undertake.