Inquest touching the death of DC (Article 2 Inquest)

Mark Bradley represented the family of the deceased who took his own life by hanging at HMP Humber.

The Jury found that DC died using bedding as a ligature to hang himself in his cell at HMP Humber and his intention was unknown due to him having consumed synthetic cannabinoids prior to his death.

Spice intoxication was found to be a contributory factor to DC’s death.

The Jury provided a narrative conclusion that whilst at HMP Hull, DC was referred by the Drug and Alcohol Recovery Team to mental health services but no further action was taken following a remote triage.  The lack of communication to DC regarding this decision was a failure.

Following DC’s move from HMP Hull to HMP Humber, there was no handover from psychosocial support services for substance misuse issues which was a failure in communication.

On arrival at HMP Humber, DC underwent a Healthcare reception screening which was found to be insufficient.

There was a serious failure to complete the Early Days in Custody Record by multiple prison personnel during the induction and therefore the standard of induction was insufficient at HMP Humber.

During his time at HMP Humber, DC was not allocated a keyworker which was a failure.

The Coroner issued a Prevention of Future Deaths Report to NHS England regarding the handover of psychosocial support from HMP Hull to HMP Humber.

Mark was instructed by Hudgell Solicitors.