Jury in Hull criticises “system failures” at HMP Humber and Coroner makes Regulation 28 report. Taimour Lay represented Colin Chappell, the father of the deceased.
Craig Chappell was found dead (by hanging) in his cell at HMP Humber (Everthorpe site) on 8 August 2014. The inquest, which took place over five days in August and September 2015, heard evidence that Craig was a vulnerable prisoner with mental health issues who had recently self-harmed on 17 July 2014.
An ACCT procedure, designed to safeguard prisoners at risk of self-harm/suicide, was duly opened but then closed on 18 July 2014, a decision which the independent Prison and Probation Ombudsman (PPO) report had stated was “premature” in the circumstances. There was also evidence of a failure to adequately share relevant information between prison staff or pay heed to the concerns being expressed by Craig’s father in the period leading up to the death.
The jury concluded that the death was “suicide” and, in a critical narrative conclusion, found that “system failures at HMP Humber… contributed to him taking his own life”.
Following written submissions on behalf of the family, the Coroner also issued a “Report to Prevent Future Deaths”, identifying the matters of concern as 1) no formal mechanism for communicating family concerns to relevant decision-making professionals and inadequate information-sharing; 2) insufficient guidance to prison staff on appropriate support to potential victims of abuse; and 3) inappropriate reliance by non-healthcare staff on the subject’s presentation and [articulated] views without further investigation”.