Source · Prevention of Future Deaths

Mark Holdsworth

Ref: 2016-0003 Date: 4 Jan 2016 Coroner: Richard Marshall Area: Central Lincolnshire Responses identified: 0 / 1 View PDF

Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon release.

Date 4 Jan 2016
56-day deadline 29 Feb 2016
Responses identified 0 of 1
Other related deaths

Coroner's concerns

AI summary
Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon release.
View full coroner's concerns
In the circumstances it is my statutory to report to you: Mark Anthony Holdsworth was arrested by the Police on January 2015 on suspicion of rape of his 14 year old step daughter He committed suicide in the early hours on 24th January 2015 shortly after being released from custody on police bail. Shortly prior to his arrest; other officers took the comnlainant anduher mother to Spring Lodge for an ABEINWI interview. On route, Mother] Itold the officers that Mr Holdsworth had said he would 'kill himself if released' This information was , am told, later added to the incident log but was not drawn to the attention of either the arresting officers or the custody staff or Custody Sergeant 10th The duty 23rd

There is not criticism of the risk assessment procedure undertaken by the custody staff when Mr Holdsworth was booked in at Lincoln station but it's clear that they lacked the significant information that Mr Holdsworth had very recently threatened to kill himself am not sure what time the incident log was updated (I have not seen it) but | appreciate that it is impractible to suggest that custody staff examine incident logs regularly because of the pressure of time and work:

Report sections

Investigation and inquest
On 4th February 2015 an investigation was commenced into the death of Mark Anthony Holdsworth; aged 35 years at the time of his death: The investigation concluded at the Inquest on December 2015. returned a conclusion of 'Took his life' . medical cause of death was: Ia. Multiple Injuries
Circumstances of the death
The deceased was released from Police Custody at Lincoln Police station at 00.26 hrs on 23/01/2015 following an allegation under the Sexual Offences Act 2003. He was collected by a family member and taken to his car as he wished to have a drive around. At 04.37 hrs the same morning he was laid on the train line between Lincoln and Doncaster when he was struck by a freight train: The death was confirmed by attending paramedics_
Action should be taken
am therefore making a recommendation in the following terms: Where Police Officers involved in the investigation of an offence become aware of suicide or serious self-harm by the principal suspect, they should (if are not themselves involved in the arrest of the suspect) notify the arresting officer(s) andlor the relevant Custody Sergeant of that fact as soon as reasonably practicable.

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Report details

Reference
2016-0003
Date of report
4 January 2016
Coroner
Richard Marshall
Coroner area
Central Lincolnshire

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: 29 Feb 2016.

Sent to

Lincolnshire Police

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