Sheldon Woodford · Prevention of Future Deaths report

On 11/05/2015 I commenced an investigation into the death of Sheldon Woodford, aged 24 . The investigation concluded at the end of the inquest on 23 February 2016. The conclusion of the inquest was Sheldon Woodford deliberately chose to suspend himself by a ligature but the evidence does not fully explain whether or not he intended that the outcome be fatal or that on balance he intended the outcome be fatal, to which a failure to respond to an evident risk of self harm contributed.
The deceased was detained at HMP Winchester on the 16th January 2015. He was found in his cell on the 9th March 2015 with a ligature made of bedding deliberately placed around his neck suspended from the door. He subsequently died in the Royal Hampshire County Hospital on the 12th March 2015. There was a failure to adequately identify the escalating level of risk of self harm as a result of the following: 1. Insufficient levels of staffing of both prison and healthcare.2. Inadequate appropriate ACCT training especially for temporarily promoted officers.3. Unstructured application of the ACCT process resulting in an inadequate integrated approach between prison staff and healthcare.4. On the balance of probabilities Sheldon Woodford's mental health issues are likely to have contributed to his death.
Cause of Death: Delayed Effects of Ligature Suspension

Sheldon Woodford had a history of mental health issues, and was on regular observation in prison. He was found in his prison cell hanging on the 9th March 2015. After being admitted to Royal Hampshire County Hospital intensive care unit, he remained unconscious and suffered significant hypoxic brain injury. He was deemed brain stem dead. Treatment was withdrawn and the death occurred on the 12/03/2016

(1)That in the reception process the SASH document is not identifiable to all relevant staff.
(2)Training of Officers in the ACCT processes.