Source · Prevention of Future Deaths
Michelle Barnes
Date: 24 Oct 2016
Coroner: Andrew Tweddle
Area: County Durham and Darlington
Responses identified: 0 / 1
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Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer support" note without a clear action plan, despite significant emotional risk.
Date
24 Oct 2016
56-day deadline
19 Dec 2016
Responses identified
0 of 1
Coroner's concerns
Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer support" note without a clear action plan, despite significant emotional risk.
View full coroner's concerns
In the circumstances it is my statutory t0 report to you: After the prison made a decision to prevent Michelle from further visiting her child in hospital, two officers who did not know Michelle and who Michelle did not know particularly well, were tasked to tell Michelle the news and to further confirm her child was to be taken into care. The senior of those oflicers, chose not t0 open an ACCT, notwithstanding she described Michelle as being very upset and cryving but instead made 17th two 18 Rrison duty an entry in the wing observation book that staff were to "offer support" It should have been clear to all that Michelle was likely to be upset upon receiving such news. Nothing was documented to indicate or t0 explain what "support" could or should be offered by staff: There was no clear plan as to what the officer meant by the entry or to what should be delivered. Is there some means of offering support short of an ACCT, was an issue raised by the evidence.
Report sections
Investigation and inquest
On December 2016 commenced an investigation into the death of Michelle Barnes. The investigation concluded at the end of the inquest on 23rd October 2016 The conclusion of the inquest was
1. Michelle deliberately hanged herself but at the time she did so her intention is unclear:
2. On a balance of probabilities (that is to say it is more likely than not) the fact that Michelle Barnes was not on an open ACCT at the time of her death probably contributed more than minimally or trivially to her death:
3. On a balance of probabilities (that is to say it is more likely than not) the decision to terminate visits to University Hospital of North Durham (made on the 15.12.2015) probably contributed more than minimally or trivially to her death:
4. On a balance of probabilities (that is to say it is more Iikely than not) the lack of further input from the mental health team at HMP Low Newton in the period 02.12.2015 16.12.2015 probably contributed more than minimally or trivially to her death:
1. Michelle deliberately hanged herself but at the time she did so her intention is unclear:
2. On a balance of probabilities (that is to say it is more likely than not) the fact that Michelle Barnes was not on an open ACCT at the time of her death probably contributed more than minimally or trivially to her death:
3. On a balance of probabilities (that is to say it is more likely than not) the decision to terminate visits to University Hospital of North Durham (made on the 15.12.2015) probably contributed more than minimally or trivially to her death:
4. On a balance of probabilities (that is to say it is more Iikely than not) the lack of further input from the mental health team at HMP Low Newton in the period 02.12.2015 16.12.2015 probably contributed more than minimally or trivially to her death:
Circumstances of the death
Michelle was sentenced to years imprisonment and arrived at HMP Low Newton on 25ih June 2015. She was found to be pregnant at a first reception health screening on arrival; An ACCT was opened immediately upon arrival at the prison and this was closed on 23" July: A second ACCT was opened on 28ih September and closed on 30" November 2015. Her baby was born on December 2015, she returned to after giving birth on 13lh December 2015 and was found dead in her cell on December 2015
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power t0 take such action Your RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19th December 2016. |, 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 no action is proposed:
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Report details
- Date of report
- 24 October 2016
- Coroner
- Andrew Tweddle
- Coroner area
- County Durham and Darlington
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: 19 Dec 2016.
Sent to
- NOMS, Prison Service, Equality Rights and Decency Group