Source · Prevention of Future Deaths
Levi Cronin
Ref: 2017-0287
Date: 6 Oct 2017
Coroner: Peter Dean
Area: Suffolk
Responses identified: 0 / 3
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Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording of observable changes on prison wings also hindered effective dynamic risk assessments.
Date
6 Oct 2017
56-day deadline
22 Jan 2018 est.
Responses identified
0 of 3
Coroner's concerns
Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording of observable changes on prison wings also hindered effective dynamic risk assessments.
View full coroner's concerns
In the circumstances it is my statutory duty_to report to YoU Log time, losing flat, day very hung
During the inquest; concerns and questions arose about: The sharing of information between healthcare staff and prison staff; while accepting the importance of medical confidentiality and consent The recording of 'Static' or 'historical' risk information (on a need to know basis) in a form that would make it more readily accessible to those at a later stage who might have to assess a changing situation and make a new dynamic risk assessment following a recent 'trigger' event The importance of ensuring that there is adequate and appropriate recording on prison wings of potentially significant event or observed changes in a person's mood or behaviour that could, if all were taken together; assist staff in their very difficult task of making risk assessments the complex and challenging environment of a busy prison.
During the inquest; concerns and questions arose about: The sharing of information between healthcare staff and prison staff; while accepting the importance of medical confidentiality and consent The recording of 'Static' or 'historical' risk information (on a need to know basis) in a form that would make it more readily accessible to those at a later stage who might have to assess a changing situation and make a new dynamic risk assessment following a recent 'trigger' event The importance of ensuring that there is adequate and appropriate recording on prison wings of potentially significant event or observed changes in a person's mood or behaviour that could, if all were taken together; assist staff in their very difficult task of making risk assessments the complex and challenging environment of a busy prison.
Report sections
Investigation and inquest
At the conclusion of the inquest into the very sad death of LEVI CRONIN, the jury recorded conclusion of 'Suicide' but also found that 'there was series of interconnected system inadequacies and failures which contributed to the death' these being: 'Insufficient recording of information. For example, inadequate recording of information in NOMIS and the Wing Observation such as recording of phone calls indicating welfare and other concerns_ 'Insufficient communication. For example lack of information sharing between departments on Levi's welfare. 'Inadequate staffing levels, at the within mental health department and prison officer staff. For example, failure of offender supervisor to see Levi in a timely manner; failure to follow up within a timely manner after referral to mental health department and subsequent appointments_ and 'Inadequate support and supervision to the mental health department
Circumstances of the death
Levi Cronin died in very tragic circumstances and was confirmed deceased at the West Suffolk Hospital having been taken there from HMP Highpoint where he was serving prisoner and had been found hanging in the shower on his wing: Levi had a history of depression and self harm and had a number of current concerns in that he was worried about his which was subject to a repossession order; had worries about his relationship and had received & letter from his girifriend during the last week;, and was anxious to obtain release on Home Detention Curfew so that he could continue plumbing course he was very motivated to carry on with. Levi was not able to meet his offender supervisor to discuss this, due to apparent staff shortages; and it was also clear that there had been considerable staffing problems in respect of mental health staff as well as prison staff: On the of his sad death, as he had run out of credit; Levi was allowed to use an office telephone to speak to his girlfriend by an officer who remained present for what was clearly a difficult and emotional phone call Sadly, Levi himself in the shower later that day.
Action should be taken
While it is accepted that much has already been done by staff and management at the prison to try and reduce the risk of similar fatalities and that; in this particular tragedy, even those closest to Levi did not foresee what was about to occur; would respectfully ask that attention and consideration is given by both prison and healthcare staff to the matters found and outlined above to try to reduce the risk of further fatalities.
Copies sent to
17 days Peter
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Report details
- Reference
- 2017-0287
- Date of report
- 6 October 2017
- Coroner
- Peter Dean
- Coroner area
- Suffolk
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Jan 2018 (estimated).
Sent to
- HMP Highpoint
- HM Prison and Probation Service
- NHS England