Source · Prevention of Future Deaths
Damion Anthony Andre Martin
Ref: 2013-0280
Date: 30 Oct 2013
Coroner: Martin Fleming
Area: Liverpool
Responses identified: 0 / 3
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Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.
Date
30 Oct 2013
56-day deadline
12 Feb 2014 est.
Responses identified
0 of 3
Coroner's concerns
Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.
View full coroner's concerns
the inquest the following = concerns were highlighted by the evidence: the initial prison reception and risk assessment; the domestic nature of Mr Martin'$ alleged charges of Common Assault and Witness Intimidation against his girl friend were not identified, notwithstanding it was considered to be a known suicidal risk factor: The first officer to respond to Mr Martin did not commence CPR sine he felt out of date with his first aid_ This raised concerns that there is no refresher 'training or a of refresher training in basic life support The observation window to the w.c area of cell 5 had a restricted view which did not extend to the area of the W.c Mr Martin was found hanging: Notwithstanding documentation to the contrary, a officer upon his roll check at approximately 5.15am did not visit Mr Martin' s cell. RT3589 against being prison during from from down During " During " prison cycle prison
Iwould ask that you give consideration to these above concerns
Iwould ask that you give consideration to these above concerns
Report sections
Investigation and inquest
On 13/12/2011 Mr Andre Rebello, HM Coroner for Liverpooly opened the inquest into the death of Damion Anthony Andre Martin, who at the date his death was 36 years old. The inquest was resumed and concluded on 23/10/2013 before a jury_ The jury found the cause of death to be: la - Hanging RT3589
Thejury concluded by finding that Damion Anthony Andre Martin took his own life.
Thejury concluded by finding that Damion Anthony Andre Martin took his own life.
Circumstances of the death
Liverpool Magistrates remanded Damion Anthony Andre Martin in custody to HMP Liverpool on 6/12/11 for alleged offences of Common Assault and Witness intimidation his partnerb Upon transfer to the prison, Mr Martin undertook initial reception and medical examination and cell share risk assessment; where it was identified that he was a first time prisoner; before placed in cell 5, landing 4 on G wing with cell mate l Mr Martin' s cell was visited several times during the role check at approximately 5.15am 11/12/11by a officer_
Action should be taken
In my action should be taken to prevent future deaths and I believe that Mr John Illingworth; Governor to HMP Liverpool has the power take such action:
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Report details
- Reference
- 2013-0280
- Date of report
- 30 October 2013
- Coroner
- Martin Fleming
- Coroner area
- Liverpool
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Feb 2014 (estimated).
Sent to
- NOMS
- HMP Liverpool
- Rights and Responsibilities Group