Angela Smith

[51] Although I do not find established that system failures contributed to Angela Smith’s death, I consider the evidence which emerged in this long inquiry should be examined by the police service and NHS to ensure at-risk prisoners are flagged up with all relevant information known about the risk.

Where a nursing assessment is indicated this should be carried out promptly and the results assessed by the duty sergeant to determine whether the risk level has increased or not.

The frequency of observations may need to be increased and the quality of these observations should be such that they are of assistance to the nursing staff in determining whether a re-assessment is required.

[52] Nurses and doctors operating from custody suites are welcome steps forward but consideration should be given to joint training and co-location of staff to improve the flow of information on the condition of at-risk prisoners.