Source · Prevention of Future Deaths
Craig Chappell
Date: 8 Sep 2015
Coroner: Rosemary Baxter
Area: East Riding and Kingston Upon-Hull
Responses identified: 0 / 1
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Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also lacked sufficient guidance on supporting potential abuse victims, relying inappropriately on presentation.
Date
8 Sep 2015
56-day deadline
3 Nov 2015
Responses identified
0 of 1
Coroner's concerns
Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also lacked sufficient guidance on supporting potential abuse victims, relying inappropriately on presentation.
View full coroner's concerns
There was no formal mechanism for communicating family concerns to relevant decision making professionals and inadequate information sharing: (2) There was insufficient guidance given to prison staff on appropriate support for potential victims of abuse. There was on occasions some inappropriate reliance by non health care staff on the subject's actual presentation and the subject's own views without investigating this further:
Report sections
Investigation and inquest
On 8 August 2014 commenced an investigation into the death of CRAIG CHAPPELL AGED 35 YEARS The investigation concluded at the end of the inquest on 2 SEPTEMBER 2015. The conclusion of the inquest was SUICIDE together with the following NARRATIVE Based on the evidence provided we the Jury conclude Craig Chappell had reached a crisis point: A number of factors within his personal life together with some system failures at HMP Humber (Everthorpe Site) contributed to him taking his own life. The medical cause of death was Ia Hanging II Alcohol and mixed drug intoxication
Circumstances of the death
The deceased was found hanging in his cell at HMP Humber Everthorpe Site by staff at approximately 0630 hours on 8 August 2014. He had previously been subject to an ACCT document but this had been closed on 18 July 2014 having been open for some 24 hours or SO only. Prior to his death he had been drinking Hooch which he had obtained in the prison and had taken prescription drugs_ He suffered from depression issues which had been exacerbated by the recent death of his mother in December 2013,his own father's illness, he had suffered sexual abuse and had suffered constant pain in his leg following a below knee amputation: He had been receiving counselling in prison.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:
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Report details
- Date of report
- 8 September 2015
- Coroner
- Rosemary Baxter
- Coroner area
- East Riding and Kingston Upon-Hull
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: 3 Nov 2015.
Sent to
- HMP HUMBER (EVERTHORPE SITE)