An inquest jury at Surrey Coroner’s Court has returned critical narrative conclusions following a three-week inquiry into the death of Matthew Russell. Tragically, Mr. Russell hanged himself at HMP High Down on 5 April 2015.
Mr. Russell had been found with possible ligatures on at least five previous occasions. Nevertheless, his observations levels were set at the same level at each of his eight Assessment, Care in Custody & Teamwork (ACCT) case reviews regardless of the level of risk recorded in the ACCT.
The jury recorded a conclusion of suicide and a damning narrative conclusion finding “multiple failures” in the way in which Mr. Russell’s ACCT plan was managed. They also made critical findings about the standard of care provided by both the InReach and Primary Healthcare teams which they said “contributed to an overall failure to adequately support Matthew’s needs”. The evidence disclosed an acute lack of training of prison officers on ACCT procedures and, in particular, on how to properly assess risk of harm.
HM Senior Coroner Mr. Travers announced his intention to make a Regulation 28 report to prevent future deaths (PFD) to the Governor of HMP High Down, the Secretary of State for Justice, Central and North West London NHS Trust (providing current InReach care) and ACHOR (providers of GP services). The report will focus on the provision and requirement for staff to undertake both induction and ongoing ACCT training and various other matters.