Source · Prevention of Future Deaths

Sheldon Woodford

Ref: 2016-0189 Date: 16 May 2016 Coroner: Sarah Whitby Area: Hampshire Central Responses identified: 0 / 1 View PDF

Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.

Date 16 May 2016
56-day deadline 11 Jul 2016 est.
Responses identified 0 of 1
State Custody related deaths

Coroner's concerns

AI summary
Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.
View full coroner's concerns
During the course f the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken _ (1)That in the reception process the SASH document is not identifiable to all relevant staff (2)Training of Officers in the ACCT processes_

Report sections

Investigation and inquest
On 11/05/2015 | commenced an investigation into the death of Sheldon Woodford, aged 24 investigation concluded at the end of the inquest on 23 February 2016. The conclusion of the inquest was Sheldon Woodford deliberately chose to suspend himself by a ligature but the evidence does not fully explain whether or not he intended that the outcome be fatal or that on balance he intended the outcome be fatal, to which a failure to respond to an evident risk of self harm contributed. The deceased was detained at HMP Winchester on the 18th January 2015. He was found in his cell on the 9th March 2015 with a ligature made of bedding deliberately placed around his neck suspended from the door: He subsequently died in the Royal Hampshire County Hospital on the 12th March 2015. There was a failure to adequately identify the escalating level of risk of self harm as a result of the following: 1. Insufficient levels of staffing of both prison and healthcare.2. Inadequate appropriate ACCT training especially for temporarily promoted officers.3_ Unstructured application of the ACCT process resulting in an inadequate integrated approach between prison staff and healthcare.4. On the balance of probabilities Sheldon Woodford's mental health issues are likely to have contributed to his death Cause of Death: Delayed Effects of Ligature Suspension
Circumstances of the death
Sheldon Woodford had a history of mental health issues, and was on regular observation in prison. He was found in his prison cell hanging on the 9th March 2015. After being admitted to Royal Hampshire County Hospital intensive care unit; he remained unconscious and had suffered significant hypoxic brain injury: He was deemed brain stem dead. Treatment was withdraw and the death occurred on the 12/03/2016
Action should be taken
Coroner' $ Office Castle Hill, The Castle; Winchester; S023 SUL Tel 01962-667884 Fax 01962-667893 The

In my opinion action should be taken to prevent future deaths and believe you Head of Safer Custody HMP Winchester have the power to take such action:
Copies sent to
667884 Fax 01962667893

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Report details

Reference
2016-0189
Date of report
16 May 2016
Coroner
Sarah Whitby
Coroner area
Hampshire Central

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 2016 (estimated).

Sent to

HMP Winchester

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