Craig Bell

On December 2012, ! commenced an investigation into the death of Craig Douglas Bell, aged 41. The investigation concluded at the end of the inquest on 27th February 2015. The cause of death was found to be: Ia Hanging The conclusion of the returned by the jury was by reference to the sections on the Record of Inquest as follows: Section 3 Craig Douglas Bell took his own life by a self constructed ligature from his bed sheets which was suspended from the wire mesh on the windows, on 13th December 2012 in cell C4-08 on C wing of HMP Manchester, Southall Street; Manchester. He did so when suffering from a mental disorder; namely a form of personality disorder; but we were unable to determine precisely which one. Craig Bell died some time before 12.20 but after 07:00. He was in an ordinary cell as there were no safer cells available on wing: No CCTV cells were in use at the time. The 24th using

Section 4 Narrative conclusion: Craig Douglas Bell spent long periods of his life within the prison system. Whilst at HMP Manchester in residence on H and K wing Craig was subject to threats and bullying which were proved to be detrimental to Craig's mental state. These issues were not correctly addressed due to inadequate procedures_ On several occasions it is documented that Craig would hang himself or end his own life_ Craig's level of risk to himself was underestimated, his intentions were clearly stated by himself. monitoring of Craig over his final few days was inadequate and insufficient. Basic prison procedures were not followed for locking and unlocking on 13th December 2012. ACCT document procedures were not followed in accordance to guidelines within paperwork: Staff were lacking knowledge of Craig's previous mental histories.

The above named was born on 7th June 1971 and was found dead in his cell at about 12.20hrs on 13th December 2012 in HM Prison Manchester. His death was reported to me and authorised a Home Office forensic post mortem examination. also opened an inquest, which was resumed sitting with a jury on 9th February 2015 and concluded on 27th February. attach a copy of the Record of Inquest with the jurors' names redacted. The deceased claimed to have been sexually abused as a child over many years. Following this, he came into contact with the criminal justice system and committed a number of offences This also resulted in him serving several periods of imprisonment: In May 2011 he was arrested after committing a series of offences. He also suffered from substance misuse problems and had a history of self harm and suicidal ideation. He was transferred to HMP Preston , where he was seen by a Forensic Psychiatrist; but no formal diagnostic impression of his mental health was made or recorded: The deceased was managed on an ACCT in HMP Preston since August 2011_ He was, however, seen by a Consultant Psychiatrist who prepared a report for the purposes of sentencing: This psychiatrist formed the opinion that the deceased was suffering from an antisocial personality disorder , a post-traumatic stress disorder, a mild depressive disorder and also a substance misuse dependence disorder He was transferred to HMP Manchester in November 2011 and was subject to ACCT procedures. He was admitted to the Health Care Centre HCC and was kept in a safer cell: In April 2012, the ACCT was closed and he was transferred to an ordinary wing location. From about the middle of March 2012, he was voluntarily seeing a psychologist as part of a pilot study in order to reduce the risk of self harm and suicide. His sessions with the psychologist ended on the Sth September 2012. Part of his therapy included cognitive behavioural therapy which he said he found helpful: psychologist gave evidence and told the court that she regarded his claims of being sexually abused as genuine and that his presentation was entirely consistent with that having occurred: The court also received evidence from the lead Psychologist at the prison who confirmed that a very high proportion of prisoners will suffer from personality disorders or traits of personality disorders. He did work with a team but there was a 5 or 6 month waiting list for patient prisoner to see him . He only worked 1 a week However, during the period on ordinary location, he complained of being subject to threats and intimidation and being called a 'grass' He had been moved from one to another.Despite this the appropriate social behaviour document was not opened The The day wing anti despite the fact that the identity of one or more of the alleged perpetrators was identified: This did not appear t0 be accordance with HMPS procedures. On 6th September 2012 the deceased reported that he had taken an overdose of medication and was admitted to hospital for assessment; tests and observation. He was relatively quickly discharged and initially returned to the HCC. On or about 20th September; he was moved to another ordinary location, but discovered that one of the prisoners who had previously been threatening him was now also on that wing: On 26th September, he disclosed thoughts of active suicidal ideation and immediately was seen and assessed by the wing manager: He was subject to a period of constant observations, in practical terms, before being moved to the HCC again and placed in a safer cell: He had previously said that he could not successfully harm himself in a safer cell, particularly unusual feature was that he had no wish to be released from custody and regarded prison as home: Indeed, he described that he felt safe in prison: The Forensic Psychiatrist who carried out a clinical review thought that this was particularly note worthy and not some he had encountered in 15 years_ In the HCC, he was subject to a 2 man unlock: Unfortunately the clinical reviewer was unaware of this and only learned the true position when giving evidence at the inquest This means that the deceased could not be released from his cell unless there were two members of staff available to supervise him at all times In addition , the other prisoners on the HCC had to be locked in their cells when he was out of his. He had described a serious and severe hatred of paedophiles and that he would attack anyone who he regarded as being one: This also meant that he was spending very considerable amounts of his time in his cell: On 23rd October , a case conference was held, He had been seen on a number of occasions by a non-Consultant grade ) Psychiatrist who had begun to form the clinical impression that he suffered from a borderline personality disorder. It was felt that there was no clinical justification for him still to remain on the HCC He was then seen for the first and only time on the 27 November 2012 by his Consultant Psychiatrist in charge of his care and management in HMP Manchester. This was in conjunction with the other less experienced Psychiatrist: The clinical record confirmed that he was on an unlock protocol in the HCC During the assessment;, he stated that he wants to commit suicide and will do it 'a million percent'. He reiterated his claims of sexually abused: He had described t0 a number of psychiatrists since his arrest in May 2009 that he was suffering from hallucinations, but these were not regarded as symptoms of a psychotic disorder; but consistent with some form of personality disorder. He had been prescribed and was a modest dose of antidepressant medication and a low dose of Quetiapine, used an anxiolytic and mood stabiliser: The last sentence of the clinical review read: 'To discuss with the Governor on the management of risk once he is transferred outside the Health wing:' An ACCT had been opened again on 6th September and there had been a number of case reviews (13.9.12,20.9.12,26.9.12 x 2, 1.10.12,8.10.12,27.10.12,6.11.12, 20.11.12 and 6.12.12). He had not wished to the HCC and had threatened to harm himself should that happen. Following the assessment by the psychiatrist on 27th November 2012, he was not seen again by any Psychiatrist up until and including 6th December 2012 On that he had a case review in the HCC, which was not attended by any Psychiatrist; or anyone from the Mental Health In-reach Team. The risk of his self harm or suicide was regarded as raised and the summary of the review said that there had been previous discussions with two previous psychiatrists but there was no clinical reason for him t0 remain in the HCC These psychiatric contacts were respectively at the last review in November and involved another Consultant Psychiatrist who only made one clinical in late October 2012 wing thing being taking leave day; entry

He was meant to see a Psychiatrist within two weeks of his move to an ordinary wing location and that the MHIT was tasked to follow up on him. An MHIT referral was duly made and he was placed on the waiting list: However, by 13th December, he had not seen the Psychiatrist or indeed anybody from the MHIT. The recording of his ACCT required interactions and observations was far from clear and several witnesses reported different understandings of what the requirements were. It was believed that prior to him leaving the HCC on 6th December 2012, he was occupying a non-safer cell having been moved there from a safer cell after a period of time but it was not possible to determine how long this had been the position. Unfortunately this was another factor the clinical reviewer was unaware of until giving evidence. Upon his transfer to C-wing; the staff there did not know or appreciate that he was regarded as suffering from mental disorder (potentially some form of personality disorder of what ever type ) and also PTSD and a depressive disorder) . Furthermore, the Senior Officer who attended this case review did not recall that the deceased had threatened to do something to himself if he were moved although this was clearly documented and another senior Nurse who attended this meeting said that is what happened: In addition the Senior Officer was unaware of the deceased's direct threat of suicide made on the 27 November 2012 but had she been told this would have prompted her to query if C wing was the right location for the deceased. It seems that just before his move to C-wing, he was subject to three daily interactions and three nightly observations. C-wing did not have any safer or CCTV monitored cells. He also had a Cell Sharing Risk Assessment which meant he had to occupy a cell alone. Upon his transfer, it appeared that the number of daily interactions increased to 5,and the night time observations were 4. He was only on the wing a few days and kept himself very much to himself. spent long periods of time in his cell, although he was on the outer part of the wing and could have spent more time out of his cell: He did get a job as a wing painter: No specific officer on duty was allocated to do the ACCT checks during the daytime and on the 8th, 9th and IOth December from about 07.OOhrs until midday, there was no recorded checks at all, He was seen before 09.OOhrs on 11th; and did attend an ACCT review, which took place later that morning: A member of the MHIT was contacted by phone, but never attended in person. No Psychiatrist was in attendance, nor any member of the MHIT who had knowledge of him. He presented to the Senior Officer leading the case review as improved. His level of daily interactions appeared to be reduced to 4, from 5. The following on 12th December, again he was not subject to any checks in the morning from 07.OOhrs until midday_ On 13th December, once again there were no checks on him after about 07.OOhrs until he was found in his cell at about 12.2Ohrs. When his cell had been opened up that morning; even though he was subject to ACCT procedures, the officer doing so never went into the cell to check that he was still alive and well: The evidence demonstrated clearly that this should have taken place, and that he should have been subject to one or more contacts the morning before lunchtime, in view of the fact that he was on an

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action

Section 3 Craig Douglas Bell took his own life by a self constructed ligature from his bed sheets which was suspended from the wire mesh on the windows, on 13th December 2012 in cell C4-08 on C wing of HMP Manchester, Southall Street; Manchester. He did so when suffering from a mental disorder; namely a form of personality disorder; but we were unable to determine precisely which one. Craig Bell died some time before 12.20 but after 07:00. He was in an ordinary cell as there were no safer cells available on wing: No CCTV cells were in use at the time. The 24th using

Section 4 Narrative conclusion: Craig Douglas Bell spent long periods of his life within the prison system. Whilst at HMP Manchester in residence on H and K wing Craig was subject to threats and bullying which were proved to be detrimental to Craig's mental state. These issues were not correctly addressed due to inadequate procedures_ On several occasions it is documented that Craig would hang himself or end his own life_ Craig's level of risk to himself was underestimated, his intentions were clearly stated by himself. monitoring of Craig over his final few days was inadequate and insufficient. Basic prison procedures were not followed for locking and unlocking on 13th December 2012. ACCT document procedures were not followed in accordance to guidelines within paperwork: Staff were lacking knowledge of Craig's previous mental histories.