Source · Prevention of Future Deaths

Steven Trudgill

Ref: 2016-0210 Date: 6 Jun 2016 Coroner: Peter Dean Area: Suffolk Responses identified: 0 / 1 View PDF

HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was not implemented.

Date 6 Jun 2016
56-day deadline 1 Aug 2016 est.
Responses identified 0 of 1
State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary
HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was not implemented.
View full coroner's concerns
_ Steven Trudgill had a long and complex mental health history dating back to his childhood with a range of different treatments and different possible diagnoses It was also clear that he had formed good and meaningful longstanding therapeutic relationships with mental health professionals in the recent past and, although he had expressed a wish not to go onto the mental health caseload in his new prison during his short time adjusting and settling in after his transfer to HMP Highpoint; he had been CO-operative and compliant with treatment in the past (after a period of non compliance), and there was no reason to believe from the detailed picture that the evidence gave of Steven, that this could not be achievable again. He was clearly a young man with some insight and some complex mental health issues, and the firesetting offences and behaviour, longstanding in his case, for which he had been convicted was a form of behaviour; according to' the forensic psychologists' report, that could, in some cases, have a significant underlying psychological component The same detailed psychological report also identified five main factors which had been recognised to_underlie_deliberate_fire_setting_behaviour,_and_found_they_could_all_be Her related to Steven's own history. was also stated that there are currently no standardised treatment programmes for fire setters available within HM Prison Service, a pilot that had been running was no longer accepting referrals: A Therapeutic Community, after further assessment of Steven's personality, was suggested option for Steven's care and treatment; but this option, also contained in the same psychology report prepared for the probation service in advance of any future parole hearing, was never taken forward as Steven sadly died before any further parole hearing took place

Report sections

Investigation and inquest
On the 24th of May 2016, concluded the inquest into the very sad death of STEVEN
Circumstances of the death
Steven Trudgill was found hanging in his cell at Majesty's Prison Highpoint on the 9th of January 2014. At the time of his death he was on an open ACCT (Assessment; Care in Custody and Teamwork) document He had been remanded into custody at the age of 18 in November 2008, charged with arson with intent to endanger life, was convicted in March 2009 and received an indeterminate sentence for public protection with a minimum period to serve of two years and two months before he could be considered for release_ He had been moved from HMP Blundeston, which was due to close, to HMP Norwich on the g"h of December 2013, and then to HMP Highpoint on the 18th of December 2013_
Action should be taken
In my opinion action should be taken to prevent future deaths. It goes without saying that no criticism is implied or intended of Steven's indeterminate sentence itself; and there was also evidence of good quality mental health care having been provided to Steven previously while he was in prison. However; it was clear from evidence given that IPP's have now been stopped, and it is also likely to be the case that there are other potentially vulnerable prisoners like Steven who are still on IPP's within the prison system and at significant risk of continuing self harm after serving their tariff, finding themselves in a system where the Parole Board hearings that provide the only possible means by which they could be released are infrequent; only occurring two or three years: It is also the case that there are complex mental health needs which might actually be the reason for the continuing risk that keeps then in custody, as with Steven, yet the specific treatments are not available within the prison service, notwithstanding good care undoubtedly provided by good practitioners in difficult circumstances To try to reduce the risk of future tragedies and fatalities like Steven's sad death occurring, am writing to you as Prisons Minister to respectfully request that consideration now be given to assessing those prisoners currently still within the prison service on IPP's to see if they actually have mental health needs which would be better ad more appropriately managed within the mental health service rather than the prison service, but within an appropriately secure unit: The aim of this would be to ensure that the appropriate level and form of mental healthcare can be provided to them in the most suitable environment in order to manage their underlying condition and reduce the risk of suicide, reduce future risk to the public and give care that might enable them to be more safely released in future, while still providing current public protection by virtue of the security of the unit
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Report details

Reference
2016-0210
Date of report
6 June 2016
Coroner
Peter Dean
Coroner area
Suffolk

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: 1 Aug 2016 (estimated).

Sent to

Ministry of Justice

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