Source · Prevention of Future Deaths
Daniel Byrne
There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.
Date
14 Dec 2015
56-day deadline
8 Feb 2016 est.
Responses identified
0 of 2
Coroner's concerns
There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.
View full coroner's concerns
_ In the Independent Investigation Report from the Prison and Probation Ombudsman, the author refers to previous deaths at Woodhill and says: Mr Byrne's was the seventh self inflicted death at Woodhill since 2013 and there have been two since. We are concerned that many of the same issues have been repeated in a number of their investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners_ My concern is that during the evidence from the Nursing Staff, it appears that they did not participate in the health screen at reception or at the first review of Mr Byrne's
Report sections
Investigation and inquest
On 21d March 2015 | commenced an investigation into the death of Daniel Brendan Byrne, aged
28. The investigation concluded at the end of the inquest on 14th December 2015. The conclusion of the inquest was that 'There was a failure by both the healthcare staff and prison officers to carry out an adequate risk assessment for self harm and suicide. There was a failure to refer Daniel Byrne for an urgent mental health assessment. There was a failure to carry out the first ACCT case review adequately. Daniel Byrne deliberately chose to suspend himself by a ligature but we are not satisfied that he intended that the outcome be fatal.
28. The investigation concluded at the end of the inquest on 14th December 2015. The conclusion of the inquest was that 'There was a failure by both the healthcare staff and prison officers to carry out an adequate risk assessment for self harm and suicide. There was a failure to refer Daniel Byrne for an urgent mental health assessment. There was a failure to carry out the first ACCT case review adequately. Daniel Byrne deliberately chose to suspend himself by a ligature but we are not satisfied that he intended that the outcome be fatal.
Circumstances of the death
The circumstances of his death are that he died on 27th February 2015 at Milton Keynes Hospital following resuscitation after a suicide attempt in his cell between 12.30-1.OOpm on 26th February 2015 at Woodhill Prison. He made a ligature from sheets in his cell and himself by the neck from the external grill outside the window of his cell: His cause of death was given after post mortem examination as 1a) Severe Hypoxicllschaemic Brain Injury Following Hanging (With Initial Resuscitation).
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
Similar PFD reports
Report details
- Date of report
- 14 December 2015
- Coroner
- Thomas Osborne
- Coroner area
- Milton Keynes
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Feb 2016 (estimated).
Sent to
- Ms Claire Murdoch, Chief Executive, Central and
- Northwest London NHS Trust