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Islington Tribune - by TOM FOOT
Published:5 December 2008
Prison criticised over death of inmate on
suicide watch

CRITICISMS surrounding the death of an inmate found hanged in Pentonville while on “high-risk” suicide watch have forced the prison’s governor to overhaul its monitoring procedure, an inquest has heard.
Duncan Edwards, 37, was placed under one-to-one care in the prison’s health centre after he was found in his cell making a noose out of bed sheets.
But despite doctors warning he was a “high-risk” inmate, Mr Edwards was discharged back to his cell. No follow-up mental health assessments were made.
After learning his girlfriend “no longer loved him” in a telephone conversation, Mr Edwards was found hanging from a ligature at the prison in April.
Prisons Deputy Om­budsman Ian Truffet criticised the prisoner’s care at Friday’s inquest. He said: “I was concerned that, despite comments from doctors that Duncan Edwards was at the highest level of risk of self-harm, he was discharged from the health centre at all. Once arriving in the wing it is pretty clear staff were not aware what doctors had previously said.”
Mr Truffet said the prison had an “effective way of identifying those at risk of self harm”, but staff needed to be better trained in understanding the process.
Confidentiality rules preventing prison doctors from informing staff about an inmate’s mental health condition should be scrapped, he added.
The Caledonian Road prison has accepted a series of recommendations from Mr Truffet following his report into the case.
Pentonville governor Nick Walmsley said: “I have accepted all the recommendations in the report and we have set up an action plan to achieve those aims.”
“Anyone discharged in this way will automatically be followed up by the mental health team. They will get an automatic appointment with a psychiatrist at least 14 days after discharge.
“There will be training for new doctors and prison staff. The new procedures will be in place by April.”
Kits to be given to all staff will include life-saving tools and a fish-shaped knife designed for cutting down ligatures.
The inquest heard how Mr Edwards was allowed to make a telephone call to his girlfriend on April 9 because he was considered a “model prisoner”. During the call the woman told Mr Edwards “she no longer loved him”. He was found dead hours later.
St Pancras coroner Dr Andrew Reid said: “Mr Edwards was having 24 hour, one-to-one care when he was outside his cell. His case was reviewed by a psychiatrist, but he was discharged without seeing a psychiatrist. A consultant advised he be discharged even though the advice was that he remain on high-level observation on the wing. It is not clear why that was.
“In practice, high level is every 15 minutes. There was no evidence that this occurred.”
The jury of nine concluded that the hanging was a “cry for help” and that Mr Edwards may not have intended to take his life. Verdict: death by misadventure.

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