Source · Prevention of Future Deaths
Calam Atour
Ref: 2016-0461
Date: 12 Oct 2016
Coroner: David Ridley
Area: Wiltshire and Swindon
Responses identified: 0 / 1
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Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels also fails to account for the specific risks posed by the inmate population type.
Date
12 Oct 2016
56-day deadline
7 Dec 2016
Responses identified
0 of 1
Coroner's concerns
Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels also fails to account for the specific risks posed by the inmate population type.
View full coroner's concerns
In the circumstances my statutory duty is to report those concerns to you. The matter of concerns are as follows:-
Tel 01722 438900 | Fax 01722 332223 I. I am concerned that unless the staffing number issue is resolved that when Alfred & Wessex Units reopen next year it will again create a significant staffing issues and a reduction of around 20% in operational personnel. I am concerned that this level of reduction has the potential and propensity to create an unsafe system of work for the prison officers (I heard during the course of the Inquest that 1 officer who was due to attend Court to give evidence sadly was the victim of a serious assault whilst on duty at Erlestoke recently). I am concerned that with a reduction in operational staff members that there is a risk that such assaults will increase. Such assaults can result in serious injury or even worse death. I am also concerned as regards the welfare of the prisoners and as regards the ability of the prison officers as a result of the pressure on their numbers to safeguard the lives of those in prison insofar as reasonable practicable against the risk of prisoners harming themselves or others or even taking their own lives. It was clear that there was a huge amount of reliance of goodwill amongst prison staff but with the continuing pressure on staffing the reality I heard is that the goodwill gets eroded overtime, as the ability to function in the workplace becomes increasingly pressurised and more stressful. The position is not sustainable long term.
II. I fully appreciate that this issue overlaps with matters of Government policy in a time of austerity but I have made this report out of a genuine concern for both the prison officers and the prisoners at HMP Erlestoke and I am of the view that if I do not air these concerns, that I would be discharging my statutory duty as a Senior Coroner having heard the evidence.
III. It was also brought to my attention that in terms of benchmarking on the previous occasion, that it did not take into account the type of prisoners that may be sent to a particular prison. Insofar as Erlestoke is concerned, due to its rehabilitation categorisation and as regards the training and courses made available to prisoners that a considerable number of the prisoners at Erlestoke are either “lifers” or on an indeterminate prison sentence, both of these, of course, relate to serious crimes. I am concerned that not taking into account the type of prisoner when determining safe/efficient numbers of personnel could lead to a lower than safe number of personnel available for duty. This concerns overlaps and dovetails with my concern at para I. above.
Tel 01722 438900 | Fax 01722 332223 I. I am concerned that unless the staffing number issue is resolved that when Alfred & Wessex Units reopen next year it will again create a significant staffing issues and a reduction of around 20% in operational personnel. I am concerned that this level of reduction has the potential and propensity to create an unsafe system of work for the prison officers (I heard during the course of the Inquest that 1 officer who was due to attend Court to give evidence sadly was the victim of a serious assault whilst on duty at Erlestoke recently). I am concerned that with a reduction in operational staff members that there is a risk that such assaults will increase. Such assaults can result in serious injury or even worse death. I am also concerned as regards the welfare of the prisoners and as regards the ability of the prison officers as a result of the pressure on their numbers to safeguard the lives of those in prison insofar as reasonable practicable against the risk of prisoners harming themselves or others or even taking their own lives. It was clear that there was a huge amount of reliance of goodwill amongst prison staff but with the continuing pressure on staffing the reality I heard is that the goodwill gets eroded overtime, as the ability to function in the workplace becomes increasingly pressurised and more stressful. The position is not sustainable long term.
II. I fully appreciate that this issue overlaps with matters of Government policy in a time of austerity but I have made this report out of a genuine concern for both the prison officers and the prisoners at HMP Erlestoke and I am of the view that if I do not air these concerns, that I would be discharging my statutory duty as a Senior Coroner having heard the evidence.
III. It was also brought to my attention that in terms of benchmarking on the previous occasion, that it did not take into account the type of prisoners that may be sent to a particular prison. Insofar as Erlestoke is concerned, due to its rehabilitation categorisation and as regards the training and courses made available to prisoners that a considerable number of the prisoners at Erlestoke are either “lifers” or on an indeterminate prison sentence, both of these, of course, relate to serious crimes. I am concerned that not taking into account the type of prisoner when determining safe/efficient numbers of personnel could lead to a lower than safe number of personnel available for duty. This concerns overlaps and dovetails with my concern at para I. above.
Report sections
Investigation and inquest
On the 14 May 2015 I commenced an investigation into the death of Calam ATOUR, aged 41. Calam’s Inquest was opened on the 1 June 2015 and the final hearing lasted 2 weeks commencing Monday 26 September 2016. As the circumstances of Calam’s death pointed to an unnatural death I was required to sit with a Jury. The Jury concluded that Calam died as a result of compression of the neck structures by a ligature and their conclusion and determination as regards the mechanism of death was as follows:-
“Between 9.08am and 11.37am on the 13th May 2015 Calam Atour died in his room at Erlestoke House by hanging himself by a ligature from the window.
Conclusion - Suicide. Narrative conclusion.
We have identified 5 circumstances which taken in combination made it probable that Calam Atour's likelyhood of suicide was inadequately addressed.
1. After the removal of medication on the 22nd April 2015 there was no immediate follow-up to personally explain the situation to Calam and this had an adverse effect on his state of mind. The policy which requires individuals to make their own medical appointments seems inappropriate if a medical intervention has itself caused the issue that makes an appointment necessary.
2. The ACCT opened on Calam had a significant medical component and it would be reasonable to expect that there should be sufficient medical personnel available to support the review process. This was not forthcoming. Given Calam's preoccupation with
Tel 01722 438900 | Fax 01722 332223 his medication it is possible that the lack of medical engagement in the process both exacerbated this preoccupation and lessened its effectiveness.
3. In reference to the events of the 13th May 2015; the ACCT process appears to be inadequate in identifying when immediate action may be necessary. It is possible that had Calam’s threats to take his own life triggered a mandatory response, rather than placing the decision making burden on the subjective opinion of individuals, that increased monitoring might have carried him through to the next assessment that afternoon.
4. There is a possibility that the lack of an assurance check at lunchtime on the 13th May 2015 contributed to Calam’s death.
5. There were staffing shortages and lack of coordination across the support networks for Calam. It is probable that this situation exacerbated the circumstances listed above.”
“Between 9.08am and 11.37am on the 13th May 2015 Calam Atour died in his room at Erlestoke House by hanging himself by a ligature from the window.
Conclusion - Suicide. Narrative conclusion.
We have identified 5 circumstances which taken in combination made it probable that Calam Atour's likelyhood of suicide was inadequately addressed.
1. After the removal of medication on the 22nd April 2015 there was no immediate follow-up to personally explain the situation to Calam and this had an adverse effect on his state of mind. The policy which requires individuals to make their own medical appointments seems inappropriate if a medical intervention has itself caused the issue that makes an appointment necessary.
2. The ACCT opened on Calam had a significant medical component and it would be reasonable to expect that there should be sufficient medical personnel available to support the review process. This was not forthcoming. Given Calam's preoccupation with
Tel 01722 438900 | Fax 01722 332223 his medication it is possible that the lack of medical engagement in the process both exacerbated this preoccupation and lessened its effectiveness.
3. In reference to the events of the 13th May 2015; the ACCT process appears to be inadequate in identifying when immediate action may be necessary. It is possible that had Calam’s threats to take his own life triggered a mandatory response, rather than placing the decision making burden on the subjective opinion of individuals, that increased monitoring might have carried him through to the next assessment that afternoon.
4. There is a possibility that the lack of an assurance check at lunchtime on the 13th May 2015 contributed to Calam’s death.
5. There were staffing shortages and lack of coordination across the support networks for Calam. It is probable that this situation exacerbated the circumstances listed above.”
Circumstances of the death
See Box 3 above.
Action should be taken
to address the concern highlighted above.
Inquest conclusion
-
“Between 9.08am and 11.37am on the 13th May 2015 Calam Atour died in his room at Erlestoke House by hanging himself by a ligature from the window.
Conclusion - Suicide. Narrative conclusion.
We have identified 5 circumstances which taken in combination made it probable that Calam Atour's likelyhood of suicide was inadequately addressed.
1. After the removal of medication on the 22nd April 2015 there was no immediate follow-up to personally explain the situation to Calam and this had an adverse effect on his state of mind. The policy which requires individuals to make their own medical appointments seems inappropriate if a medical intervention has itself caused the issue that makes an appointment necessary.
2. The ACCT opened on Calam had a significant medical component and it would be reasonable to expect that there should be sufficient medical personnel available to support the review process. This was not forthcoming. Given Calam's preoccupation with
Tel 01722 438900 | Fax 01722 332223 his medication it is possible that the lack of medical engagement in the process both exacerbated this preoccupation and lessened its effectiveness.
3. In reference to the events of the 13th May 2015; the ACCT process appears to be inadequate in identifying when immediate action may be necessary. It is possible that had Calam’s threats to take his own life triggered a mandatory response, rather than placing the decision making burden on the subjective opinion of individuals, that increased monitoring might have carried him through to the next assessment that afternoon.
4. There is a possibility that the lack of an assurance check at lunchtime on the 13th May 2015 contributed to Calam’s death.
5. There were staffing shortages and lack of coordination across the support networks for Calam. It is probable that this situation exacerbated the circumstances listed above.”
“Between 9.08am and 11.37am on the 13th May 2015 Calam Atour died in his room at Erlestoke House by hanging himself by a ligature from the window.
Conclusion - Suicide. Narrative conclusion.
We have identified 5 circumstances which taken in combination made it probable that Calam Atour's likelyhood of suicide was inadequately addressed.
1. After the removal of medication on the 22nd April 2015 there was no immediate follow-up to personally explain the situation to Calam and this had an adverse effect on his state of mind. The policy which requires individuals to make their own medical appointments seems inappropriate if a medical intervention has itself caused the issue that makes an appointment necessary.
2. The ACCT opened on Calam had a significant medical component and it would be reasonable to expect that there should be sufficient medical personnel available to support the review process. This was not forthcoming. Given Calam's preoccupation with
Tel 01722 438900 | Fax 01722 332223 his medication it is possible that the lack of medical engagement in the process both exacerbated this preoccupation and lessened its effectiveness.
3. In reference to the events of the 13th May 2015; the ACCT process appears to be inadequate in identifying when immediate action may be necessary. It is possible that had Calam’s threats to take his own life triggered a mandatory response, rather than placing the decision making burden on the subjective opinion of individuals, that increased monitoring might have carried him through to the next assessment that afternoon.
4. There is a possibility that the lack of an assurance check at lunchtime on the 13th May 2015 contributed to Calam’s death.
5. There were staffing shortages and lack of coordination across the support networks for Calam. It is probable that this situation exacerbated the circumstances listed above.”
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Report details
- Reference
- 2016-0461
- Date of report
- 12 October 2016
- Coroner
- David Ridley
- Coroner area
- Wiltshire and Swindon
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: 7 Dec 2016.
Sent to
- HM Prison and Probation Service