Source · Prevention of Future Deaths
Peter Lawrence
Ref: 2016-0314
Date: 30 Aug 2016
Coroner: Simon Milburn
Area: Cambridgeshire and Peterborough
Responses identified: 0 / 1
View PDF
The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with limited background information.
Date
30 Aug 2016
56-day deadline
25 Oct 2016 est.
Responses identified
0 of 1
Coroner's concerns
The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with limited background information.
View full coroner's concerns
(1) The inquest heard a great deal of evidence relating to the process for identifying, managing and recording risk at the first point of contact between new prisoners and prison/healthcare staff. Mr Lawrence had not been in prison before and there was very Iittle background information available to enable staff to identify less obvious risk factors , particularly in relation to the nature of the alleged offences. It was accepted in evidence that it was of particular importance at the initial screening to identify risk by other means and to record any observations in a comprehensive manner for future reference_
Report sections
Investigation and inquest
In February 2014 commenced an investigation into the death of Peter Lawrence. The investigation concluded at the end of the inquest on 08.07.16. The conclusion of the inquest was that Mr Lawrence suffered a self inflicted stab wound to the heart: The conclusion of the jury was that Mr Lawrence was a determination of suicide_
Circumstances of the death
Mr Lawrence was remanded into custody at HMP Peterborough on 06.12.14 charged with serious sexual offences. On 02.02.15 he was found slumped in a toilet cubicle in a prison workshop having stabbed himself with a chisel. He was treated and taken to hospital where death was confirmed:
Action should be taken
In my opinion action should be taken to prevent future deaths believe your organisation has the power to take such action:
Similar PFD reports
Related inquiry recommendations
IICSA
DBS and training compliance for Church officers
IICSA
DBS certificates for overseas work
IICSA
Mandatory DBS for work with children overseas
IICSA
Improve DBS Referral Compliance
IICSA
Extend Disclosure Regime Overseas
IICSA
Greater Use of DBS
IICSA
Amendment of Safeguarding Vulnerable Groups Act 2006
IICSA
CSA experience for Chief Officer progression
IICSA
Lambeth foster carer vetting review
Bichard Inquiry
Information verification confirmation
Report details
- Reference
- 2016-0314
- Date of report
- 30 August 2016
- Coroner
- Simon Milburn
- Coroner area
- Cambridgeshire and Peterborough
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: 25 Oct 2016 (estimated).
Sent to
- National Offender Management Service