Source · Prevention of Future Deaths

Sam Molyneux

Ref: 2017-0340 Date: 13 Sep 2017 Coroner: Andre Rebello Area: Liverpool & Wirral Responses identified: 1 / 1 View PDF

Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not placed on an appropriate monitoring plan (ACCT).

Date 13 Sep 2017

56-day deadline 10 Nov 2017

Responses identified 1 of 1

State Custody related deaths

Coroner's concerns

AI summary

Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not placed on an appropriate monitoring plan (ACCT).

View full coroner's concerns

During the course of the inquest it became apparent that in old prisons not all wings have been adapted to have anti-barricade doors. In this case Mr Molyneux had barricaded his door and this delayed prison staff gaining access to him during a Code Blue Situation. He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death. Local directions in the Prison during the inquest have addressed this situation in HMP Liverpool at Walton. That said HM Prison and Probation service might wish to consider amending “Management of Prisoners at risk of harm to self, to others and from others (Safer Custody)” to include consideration of where reasonably practicable avoiding locating prisoners behind a door which is not designed to circumvent barricading.

Responses

1 respondent

HM Prison Probation Service Central Government

26 Oct 2017 PDF

Action Planned

HM Prison & Probation Service will revise the ACCT form and PSI 64/2011 Safer Custody policy to direct staff to consider emergency access, including the presence of an anti-barricade door, when locating prisoners on ACCT. This will also be included in ACCT case manager training. (AI summary)

View full response

Dear Mr Rebello

Inquest into the death of Sam Molyneux

Thank you for your Regulation 28 Report of 13 September 2017 following the recent inquest into the death of Sam Molyneux at HMP Liverpool on 1 April 2016.

I know that you will share a copy of this response with Mr Molyneux’s mother and I would like first to express my condolences for her loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

Mr Molyneux was not identified as being at risk of self-harm or suicide, and was therefore not subject to ACCT procedures at the time of his death. I understand that prison staff explained the reasons for this during the course of the inquest. That

notwithstanding, you have raised concerns about those who are subject to ACCT procedures being located in cells which do not have anti-barricade doors. I am grateful to you for bringing this to my attention.

Every cell that has been built or refurbished since 2005 has an anti-barricade door, and the number of cells that do not have this facility is therefore relatively low.

Wherever possible, we should avoid using such cells to accommodate prisoners identified as being at risk of self-harm or suicide. As you know, the ACCT process includes consideration by the case review team of the most appropriate location for the prisoner. Both the design of the ACCT form and the content of PSI 64/2011 Safer Custody are currently under review, and we will ensure that the revised version of the form and accompanying policy direct staff to have regard to the issue of emergency access – including the presence of an anti-barricade door – when making decisions about the location of a prisoner on an ACCT. We will also include this in the training that is provided for ACCT case managers.

I trust that this provides assurance that the matter of concern that you have raised will be addressed.

Report sections

Investigation and inquest

On 8th April 2016 I commenced an investigation into the death of Sam MOLYNEUX , Aged 21. The investigation concluded at the end of the inquest which started on 4th September 2017 and subsequent days to the 13th September 2017. The Jury concluded that “Sam Molyneux committed suicide. We have found that Sam Molyneux put himself in the position he was found with the intention of ending his life by using a hand-made ligature made from a bed sheet to hang himself from the grill within his cell, H2-8, at 68 Hornby Road on 01/04/16 between 21.15 and 22.10. There was a failure to open an ACCT on 31st March 2016. Sam Molyneux was assaulted in the days leading up to his death by other prisoners. It is unclear as to whether HMP Liverpool and its staff responded appropriately to any assaults against Sam Molyneux. Furthermore, it is more likely than not that bullying in prison contributed at least in part to the death of Sam Molyneux.”

The medical cause of death was:

Ia Asphyxiation due to Ib Compression of the neck due to Ic Hanging by a ligature

Circumstances of the death

MOLYNEAUX was a prisoner at HMP Liverpool and was in cell 8 on H wing. This is a drug dependency wing. He was the sole occupant of the cell. He was assaulted by other prisoners on the 27th March 2017. He was subject to basic regime IEP status having broken his observation spyhole and having climbed on to the office roof. He underwent a Governors adjudication on the 31st March 2016, at which he pleaded guilty and handed the governor a letter in which he expressed thoughts of self-harm. On Friday 1st April 2016 MOLYNEAUX was seen at 21:15 hours in his cell and all was in order. At 22:10 hours the prisoner officer was conducting his checks when he has looked through the spy hole and saw that MOLYNEAUX was hanging from torn sheets that had been knotted onto the grills of the window. The officer attempted to gain access to the cell but the door had been barricaded, by the use of a table from inside the cell. The door was eventually forced and entry was gained by prison officers, where the ligature was cut and first aid commenced on MOLYNEAUX. Paramedics attended and continued with resuscitation and eventually MOLYNEAUX was pronounced life extinct at 22.55hrs 01/04/2016 by a paramedic.

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Report details

Reference: 2017-0340
Date of report: 13 September 2017
Coroner: Andre Rebello
Coroner area: Liverpool & Wirral

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Nov 2017.

Sent to

HM Prison & Probation Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.