Steven Davidson

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

The deceased died while in prison. He had been in prison on a previous occasion, in 2012- 13, during which he had self- harmed on a number of occasions, including ligaturing himself to the point of unconsciousness on more than one occasion, [REDACTED] . He had during that prison stay also been , [REDACTED] in his cell. This information was contained and documented within the System One Healthcare Records, which were available to the staff in Chelmsford Prison. However, the evidence from all of the healthcare witnesses involved, which included a number of Registered Mental Nurses carrying out a mental health review of the deceased’s care, and the Nurse conducting the initial Reception Health Screen, was that none of those people were aware of the deceased’s history. Evidence was given that such past history is clinically significant to any assessment of the risk of self harm. The evidence from some of these staff was that they had not been able to navigate the records very easily, and/or despite interrogating the records, had not found this important information. There was evidence given from senior personnel in the company involved in supplying health care to Chelmsford and other prisons that it is possible to word- search for words such as, “self harm” or “suicide”.

CORONER’S CONCE RNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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)  Health Care Staff at HMP Chelmsford say that they are: (i)          not able to navigate the System One records sufficiently well to find information about previous incidents of self- harm in prison; and/ or (ii)         not sufficiently aware of the importance of searching the records made by clinicians during previous prison stays when conducting Reception Health Screens and/ or reviews of a prisoner’s mental health needs. (iii)        May not be sufficiently trained to understand and utilise System One records to find previous history, including incidents of self- harm in custody.

In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.

You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 th December 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.