Steven Roy Davidson · Prevention of Future Deaths report

On 20th March 2024, I commenced an investigation into the death of Steven Roy Davidson. The investigation concluded at the end of the inquest on 22nd October 2025. The conclusion of the inquest was a narrative conclusion, with the jury including the finding that where he created a ligature ████████ while a convicted but unsentenced prisoner in Chelmsford Prison. They also found (albeit without it being causative) that important information about the deceased and previous acts of self- harm had not been passed on.

The deceased died while in prison. He had been in prison on a previous occasion, in 2012- 13, during which he had self- harmed on a number of occasions, including ████████ ligaturing himself to the point of unconsciousness on more than one occasion, ████████ He had during that prison stay also been ████████ in his cell. This information was contained and documented within the System One Healthcare Records, which were available to the staff in Chelmsford Prison. However, the evidence from all of the healthcare witnesses involved, which included a number of Registered Mental Nurses carrying out a mental health review of the deceased’s care, and the Nurse conducting the initial Reception Health Screen, was that none of those people were aware of the deceased’s history. Evidence was given that such past history is clinically significant to any assessment of the risk of self harm. The evidence from some of these staff was that they had not been able to navigate the records very easily, and/or despite interrogating the records, had not found this important information. There was evidence given from senior personnel in the company involved in supplying health care to Chelmsford and other prisons that it is possible to word- search for words such as, “self harm” or “suicide”.

(1) Health Care Staff at HMP Chelmsford say that they are:
(i) not able to navigate the System One records sufficiently well to find information about previous incidents of self- harm in prison; and/ or
(ii) not sufficiently aware of the importance of searching the records made by clinicians during previous prison stays when conducting Reception Health Screens and/ or reviews of a prisoner’s mental health needs.
(iii) May not be sufficiently trained to understand and utilise System One records to find previous history, including incidents of self- harm in custody.