Christopher Andrew MOSS · Prevention of Future Deaths report

On 21 February 2017 I commenced an investigation into the death of Christopher Andrew Moss aged 51 years. The investigation concluded at the end of the inquest on 25 February 2019. The conclusion of the inquest was suicide with the main cause of death being haemorrhage from incised injury to left wrist.

Basic: a) Mr Christopher Andrew MOSS was a serving prisoner at HMP Featherstone who died whilst on House Unit 6 on 18th February 2017 as a result of a self-inflicted incision to left wrist.
Probable: b) Locked cell door and restricted view via the door observation hatch; barricading of cell door.
Possible: c) Threats; state of mind

The conclusions of the investigations by the Prisons and Probation Ombudsman led to a suitable action plan being implemented at HMP Featherstone in matters relating to violence reduction, discharge from mental health team and barricade incidents.
At the incident when Christopher died initially a hydraulic jack to open the cell door was summoned to the scene when the appropriate equipment was not available (it did in fact arrive very soon afterwards). I am aware that there is a gradual process in the prison estate to move towards cell doors that can be opened outwards if necessary in addition to normally opening inwards. My concern however is that for doors that are not dual opening prisons should have appropriate equipment available to deal with barricade situations. Should there be a check or audit to ensure that the correct equipment for the relevant doors are located appropriately at prisons?