Source · Prevention of Future Deaths

Arthur Morley

Ref: 2017-0106 Date: 4 Apr 2017 Coroner: Crispin Butler Area: Buckinghamshire Responses identified: 0 / 1 View PDF

The report indicated concerns but did not provide specific details on what matters gave rise to them, making it impossible to identify key safety issues.

Date 4 Apr 2017
56-day deadline 11 Jul 2017 est.
Responses identified 0 of 1
State Custody related deaths

Coroner's concerns

AI summary
The report indicated concerns but did not provide specific details on what matters gave rise to them, making it impossible to identify key safety issues.
View full coroner's concerns
During the course of the _inquest the evidence revealed matters_giving_rise _to concernIn Coroner' $ Office; 29 Windsor End, Beaconsfield, Buckinghamshire. HP9 2JJ Tel: (01494) 475 505 Fax: (01494) 673 760 E Mail: coroners@buckscc gov.uk

Report sections

Investigation and inquest
On 23rd December 2015 Senior Coroner Richard Hulett commenced an investigation into the death of Arthur Albert MORLEY, aged 72 years_ The investigation concluded at the end of the inquest before me Crispin Giles Butler on 27 March 2017. The conclusion of the jury at the inquest was set out in the Jury's narrative conclusion contained in their answers to a questionnaire The medical cause of death was Ia Suspension: copy of the questionnaire is attached.
Circumstances of the death
Mr Morley was a prisoner serving an indeterminate sentence_ He had transferred to HMP Grendon for a second time in August 2015 to undertake therapy and at the time of his death was on the assessment wing: He had not been allocated to a more permanent therapy wing: Following assessment; the decision was made that he was not suitable for therapy at this time and he was to be returned to his previous prison (Returned to Unit or RTU): The decision was communicated to Mr Morley in a face to face meeting at the end of the morning on 7/h December 2015. Mr Morley was found hanging from a pipe in the sanitation area on his landing at approximately 00.49 on 18/h December, having accessed the interlocked night sanitation system approximately 80 minutes earlier:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
Copies sent to
475 505 Fax673 760 E Mail: coroners@buckscc gov.uk duty May duty

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Report details

Reference
2017-0106
Date of report
4 April 2017
Coroner
Crispin Butler
Coroner area
Buckinghamshire

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: 11 Jul 2017 (estimated).

Sent to

HMP Grendon

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