A coroner has taken the unusual step of writing to a prison governor to warn that a prison officer who gave evidence at an inquest risked endangering the lives of current prisoners.
The senior coroner for Derbyshire, Dr Robert Hunter, issued a prevention of future deaths report – usually sent after an inquest has concluded – during an inquest into the death of a female prisoner.
The coroner issued the report after hearing evidence from the prison officer. He wrote that if the officer remained working at the prison she would be “endangering the lives of current prisoners”.
The inquest into the death of Caroline Ann Hunt concluded on Thursday, but Hunter issued the report on 19 May while hearing evidence. Hunt, 53, killed herself on 29 September 2015at HMP Foston Hall, Derbyshire. She was the fourth woman to die at the prison that year.
After one of the prison officers involved in the case gave evidence, the coroner said he had “grave concerns about her understanding of safety procedures” and that “should she remain operational”, she endangered the lives of inmates.
The inquest heard that Hunt had been a remand prisoner at Foston Hall for two weeks. During that time she was distressed and anxious and had made repeated threats to kill herself. She made statements to that effect and other prisoners reported her suicidal intentions.
The night before she died, she attempted to kill herself and her cell mate twice warned staff of the danger. Despite these warnings, a decision was made to place Hunt in a cell by herself.
The inquest heard that the most senior prison officer on duty the day before Hunt died was suspended after her death. He faced disciplinary proceedings, but he resigned before any hearing took place.
The jury gave a narrative verdict at the inquest which found that:
Staff had not been effectively trained.
Hunt should have been referred for a psychiatric assessment.
Staff response to her cell mate’s concern about her attempted suicide was not appropriate.
She should not have been placed in a single cell.
Hunt’s daughter said her mother had mental health issues which led to her committing the offence that resulted in her being put on remand. It was her first offence. Hunt felt hopeless and frightened about her future, her daughter said.
She said there were many missed opportunities to protect her mother from risk and she was saddened to hear that a further two women had died at the jail last year.
“I had hoped my mother’s death would be the last and no other family should suffer as I have. The deaths leave families with endless pain and countless what ifs?”Deborah Coles, director of the charity Inquest, said it was shocking that 18 months after Hunt’s death a key staff member had a lamentable lack of understanding of suicide prevention policies.
“This begs questions about the state of governance at a prison where four women died in 2015.” Coles added.
The staff member whom the coroner criticised has been removed from prisoner-facing duties while she undertakes urgent training.
A spokesman for the Ministry of Justice said: “This is a tragic case and our thoughts are with Caroline Ann Hunt’s family and friends. We recognise that there were failings in her care, and HMP Foston Hall has already put in place a number of measures to better support offenders following the PPO investigation. We will now carefully consider the findings of the inquest.”