Source · Prevention of Future Deaths
Christopher MacGillivray
Ref: 2024-0297
Date: 29 May 2024
Coroner: Karen Dilks
Area: Newcastle and North Tyneside
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe Prison Service Instruction (PSI) 64/2011 does not provide mandatory procedures for communicating known self-harm risks during the unplanned release of remand prisoners. This absence of guidance raises concerns about future deaths of at-risk prisoners.
Date
29 May 2024
56-day deadline
24 Jul 2024
stated in the report
Responses identified
0 of 1
Coroner's concerns
The Prison Service Instruction (PSI) 64/2011 does not provide mandatory procedures for communicating known self-harm risks during the unplanned release of remand prisoners. This absence of guidance raises concerns about future deaths of at-risk prisoners.
View full coroner's concerns
(1) The prison service instruction (PSI) 64/2011 sets out the procedures that must be followed to manage prisoner safety. The Annex sets out a mandatory process for the planned release of a prisoner who has been on an ACCT. Offender Management in Custody (OMiC) guidance provides for direct communication between Prison Offender Manager and Community Offender Manager in respect of prisoners at risk of self harm for SENTENCED PRISONERS ONLY.
(2) The PSI is silent in respect of unplanned releases for 'prisoners on remand' with a known risk of self-harm and who may be released at short notice. There is no apparent direction/mandatory procedure for communication of the known risk of self-harm for unplanned release.
(3) There is a risk of future deaths of prisoners in the category as at para 2 above. Urgent amendment to PSI/Annex and OMiC is required to set out procedures that must be followed in the management of the unplanned release of prisoners at risk of self-harm/suicide.
(2) The PSI is silent in respect of unplanned releases for 'prisoners on remand' with a known risk of self-harm and who may be released at short notice. There is no apparent direction/mandatory procedure for communication of the known risk of self-harm for unplanned release.
(3) There is a risk of future deaths of prisoners in the category as at para 2 above. Urgent amendment to PSI/Annex and OMiC is required to set out procedures that must be followed in the management of the unplanned release of prisoners at risk of self-harm/suicide.
Report sections
Investigation and inquest
On 19 October 2021 I commenced an investigation into the death of Christopher Alistair MACGILLIVRAY. The investigation concluded at the end of the inquest . The jury reached the following conclusion: Christopher MacGillivray hanged himself by a ligature whilst under the influence of a combination of Cocaine and alcohol. 1a Pressure on the neck 1b Hanging 1c II
Circumstances of the death
Christopher Alistair MacGillivray had a long history of Drug and Alcohol issues and attempted suicide and self-harm complicated by the impact of a brain injury sustained in an assault in 2018. He was charged with criminal offences for which he was granted conditional bail and subject to a curfew.
He was also managed by Probation Service under the terms of a Probation Order for an earlier offence. On 9th October 2021 he was remanded in custody to HMP Durham for breach of his curfew. His arrest was precipitated by a member of the public who contacted police raising concerns for his welfare having seen him standing on the edge of a bridge. On 10th October Christopher Alistair MacGillivray reported thoughts of self-harm to prison staff. Suicide and self-harm prevention procedures known as ACCT (Assessment Care in Custody and Teamwork) were implemented. He was placed on hourly observations. On 12th October Christopher Alistair MacGillivray was released on bail by Magistrates following a hearing via remote link. The ACCT was then closed. There was no direct communication from Prison to his Probation Officer/Manager in respect of his release and his risk of self-harm. On 14th October Christopher Alistair MacGillivray was found hanging in his home where his death was confirmed.
He was also managed by Probation Service under the terms of a Probation Order for an earlier offence. On 9th October 2021 he was remanded in custody to HMP Durham for breach of his curfew. His arrest was precipitated by a member of the public who contacted police raising concerns for his welfare having seen him standing on the edge of a bridge. On 10th October Christopher Alistair MacGillivray reported thoughts of self-harm to prison staff. Suicide and self-harm prevention procedures known as ACCT (Assessment Care in Custody and Teamwork) were implemented. He was placed on hourly observations. On 12th October Christopher Alistair MacGillivray was released on bail by Magistrates following a hearing via remote link. The ACCT was then closed. There was no direct communication from Prison to his Probation Officer/Manager in respect of his release and his risk of self-harm. On 14th October Christopher Alistair MacGillivray was found hanging in his home where his death was confirmed.
Action should be taken
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th July 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th July 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
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Report details
- Reference
- 2024-0297
- Date of report
- 29 May 2024
- Coroner
- Karen Dilks
- Coroner area
- Newcastle and North Tyneside
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Jul 2024 (stated in the report).
Sent to
- Ministry of Justice
Non-response list
The Chief Coroner has confirmed the following did not respond within the required period:
- Ministry of Justice