Anthony Smith

I am Nicholas Leslie Rheinberg, assistant coroner for the coroner area of Lancashire and Blackburn with Darwen

An investigation into the death of Anthony George Smith aged 34 was commenced on 16th May 2022. The investigation concluded at the end of the inquest on 7th June 2023. The conclusion of the inquest was that Mr Smith died as a result of self-suspension but his intention in doing so could not be determined

Mr Smith at the time of his death at HMP Preston was suffering an acute relapse in respect of his schizophrenia. He was delusional, hallucinating and hearing voices. On 4th May 2022 he was found hanging in his cell. He was cut down and officers commenced cardio-pulmonary resuscitation

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.

1. An officer attempting resuscitation carried out mouth to mouth resuscitation without the safeguard of mouth protection which was not available in the prison at the time. Mr Smith was a regular drug user who on occasions injected drugs. Performing mouth to mouth resuscitation carried with it the risk of transmission of blood born viruses with possible fatal consequences.
2. The lack of available protection not only carried with it a risk to those who performed resuscitation but potentially also to the person suffering a cardiac arrest in that without protection the would-be resuscitator might decline to provide rescue breaths
3. Consideration should be given to informing prison governors of the need to secure a readily accessible supply of protection masks. PSI 29 of 2015 on the subject of First Aid is currently under review and might be a vehicle for providing appropriate direction.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.