Peter Lawrence · Prevention of Future Deaths report

In February 2014 I commenced an investigation into the death of Peter Lawrence. The investigation concluded at the end of the inquest on 08.07.16. The conclusion of the inquest was that Mr Lawrence suffered a self inflicted stab wound to the heart.

The conclusion of the jury was that Mr Lawrence was a determination of suicide.

Mr Lawrence was remanded into custody at HMP Peterborough on 06.12.14 charged with serious sexual offences. On 02.02.15 he was found slumped in a toilet cubicle in a prison workshop having stabbed himself with a chisel. He was treated and taken to hospital where death was confirmed.

(1) The inquest heard a great deal of evidence relating to the process for identifying, managing and recording risk at the first point of contact between new prisoners and prison/healthcare staff. Mr Lawrence had not been in prison before and there was very little background information available to enable staff to identify less obvious risk factors, particularly in relation to the nature of the alleged offences. It was accepted in evidence that it was of particular importance at the initial screening to identify risk by other means and to record any observations in a comprehensive manner for future reference. HMP Peterborough has put in place a number of measures in recognition of the concern that suicide/self harm risk is identified at the earliest stage, even if no ACCT document is opened. The concern that risk factors may be missed or inadequately recorded has been addressed locally but there may be scope to expand awareness that individuals entering prison for the first time may be accompanied by only limited information. The situation is worsened where there is limited information available about the nature of the alleged offending. The identification and communication of less obvious risk factors is crucial;

(2) The use of personal (or ‘custodial’) officers was identified as an important aspect of risk management. The jury identified the absence of interaction with a custodial officer in the current case to have been a missed opportunity to further identify and consider the risk of suicide/self harm. Again this has been addressed locally. The lack of meaningful interaction with a dedicated member of staff in a pastoral capacity, particularly for those in prison for the first time, gives rise to a concern that deaths may occur in other cases nationally.