Angela M Inquest: Communication Failures Prompt Prevention of Future Deaths Report

Ruth Bundey of our Inquest Team recently acted for the brother of Angela M, who died by drowning in Low Newton Prison on the 25^th February 2024.

Angela had three periods in Low Newton Prison in 2023, and a fourth from December 30^th 2023 until her death on 25/02/24. She had been in and out of Court previously due to a dispute with her neighbour with whom on a previous occasion Angela had left her cats, but the neighbour had them chipped in the neighbour’s name leading to a constant dispute as to whose they were, hence restraining orders against Angela and breaches of the same. Press Reports show that the Recorder of York, Sean Morris, reserved Angela’s cases to himself, saying that she needed mental health support, not prison. Prison records showed Angela as Bipolar with a history of epilepsy. No care plan was instituted.

On entering Low Newton on 30/12, Angela said she was suicidal and an ACCT, a special process for prisoners at risk of suicide and self-harm, was immediately opened. The next day in the morning she had a second health screening and told a Health Care Assistant that she would drown herself in the bath if she got the chance. The HCA recorded this comment in the Systm One medical notes ( though inaccurately, leaving out “ in the bath” which she said in her evidence was included by Angela) but did not make an entry on the  ACCT Document so that all staff involved with Angela’s ACCT would have been made aware of it. A mental health nurse filled out a further entry in Systm One 18 minutes later and saw the remark, but again did nothing to pass it on. ( Prison staff do not see the medical records.)

Angela’s ACCT was closed on 11/1/24. A further ACCT was opened on 18/1 after she said that nothing had improved and she still felt suicidal, but closed the next day. On 30/1 a third ACCT was opened: she had attended court by video link hoping to be released, but instead a psychiatric report was ordered by the Recorder of York: Angela’s counsel warned the prison that she was indicating self-harm; she was observed to be tearful during the hearing and told an officer she didn’t want to be here anymore, starting to cry, and reported thoughts of self-harm to a chaplain. Nevertheless, the ACCT was closed again the following day.

Senior prison staff, and in particular her Custodial Manager, now Head of Safety, told the Inquest that had they have been made aware of the drowning remark, which was highly unusual and abnormal, and indicated a specific plan, they would have acted differently, escalated matters, discussed with Angela, carried out risk assessments, continued her ACCT protection, considered a different location away from baths or arranged bath supervision, and remained vigilant. There was no reference whatsoever in the prison records to the remark. The Inquest Jury found that this failure of communication contributed to Angela’s death.

A high level of venlafaxine, an anti-depressant with sedative effects, was found to be in Angela’s blood stream after death, indicating that she had managed to hoard the medication from her own prescribed dosage or obtained some from another prisoner. Hence the cause of death was drowning due to high levels of venlafaxine.

Following the Inquest, the Senior Coroner for Durham and Darlington issued a Prevention of Future Deaths report to NHS England. Such a report is made where a Coroner considers that action should be taken to address circumstances which create a continuing risk that other deaths may occur.

The concern was that safety-critical information disclosed to healthcare staff was only recorded within SystmOne medical records, which prison staff could not access, without also being entered clearly on the prisoner’s ACCT document or otherwise communicated to those responsible for managing the immediate risk. In Angela’s case, her specific statement that she would drown herself was therefore missed and effectively “buried” within the medical records. The report highlighted the need for robust systems to identify, escalate and share such information promptly so that appropriate risk assessments, safeguards and supervision can be put in place.

This demonstrates the wider importance of specialist inquest representation. The work undertaken by our Inquest Team, together with the family’s engagement and determination, did not simply establish what happened to Angela: it identified a systemic safety issue and prompted a formal requirement for it to be addressed. On this occasion, that work has the potential to bring about real change in the way critical information is communicated and, ultimately, to help prevent future deaths.