After a two-week inquest, the jury has returned a highly critical narrative conclusion finding that lack of staff, training and consistent care across the prison and healthcare led to a failure to spot obvious and escalating patterns of risk regarding Sheldon’s self-harm.
Despite the self-harm warnings accompanying Sheldon’s arrival at the prison, neither the reception officer nor the first nurse who assessed Sheldon, placed him under suicide and self harm management programme in part due to the fact that vital information was not properly shared or made available. His risk of self harm and suicide was not formally assessed until ten days later, after Sheldon had cut his wrists.
The level of observations Sheldon was monitored under did not always always reflect his risk of self-harm – including staff only being required to check Sheldon twice an hour when he returned to prison after a serious suicide attempt. Meetings in relation to his risk of self harm were often not multidisciplinary and the prison staff did not receive adequate training to identify and manage his risk of self harm.
At Sheldon’s final case review, held three days after he returned from intensive care having attempted to hang himself (and five days before he placed a ligature round his neck for the second, fatal time), Sheldon’s risk was graded as “low”. This was despite the fact that the hospital who had discharged Sheldon had described him as “high risk”, a prison GP considered his risk to stem from his “impulsive” and “unpredictable” behavior, and the prison psychiatrist, told the inquest that the “low” grading was incorrect and inappropriate.
The jury retuning a highly critical narrative conclusion, found that the failure to identify Sheldon’s escalating levels of risk of self harm, insufficient levels of prison and healthcare staffing, inadequate training on how to assess and manage risks of self harm contributed to Sheldon’s death. They also identified unstructured application of the suicide and self harm management programme resulting inadequate integration between prison and healthcare as a contributory factor in his death.
The Coroner indicated that she will be making recommendations to prevent future deaths in relation to training of prison staff and officers in suicide and self harm management and also in relation to the sharing of information.
Sheldon Woodford’s partner Alex said:
“We always believed that Sheldon was badly let down by the system at HMP Winchester and we are pleased that the jury found that this was the case. To have had to visit him once in an induced coma after a hanging attempt was bad enough, but we had hoped that the prison would learn from the risks that Sheldon was clearly presenting and provide him with the care and support he needed. To have to return again to an intensive care unit less than two weeks later, and to have to make the horrendous decision to turn off his life support machine, was devastating and broke our hearts.
We hope that the jury’s highly critical findings and the coroner’s Prevention of Future Deaths Report will mean that eventually other families will not have to go through this. We also hope that the government will consider the failures in staffing levels and training which contributed to Sheldon’s death before making any further cuts to the prison system”
Alex Tasker’s solicitor Karen Rogers said:
“The failure to properly implement ACCT procedures in this case was shocking. The evidence showed there was far too much reliance on prisoners’ self-report, and insufficient attention paid to obvious and escalating risks of self-harm.”
Deborah Coles : Director of INQUEST said :
“Sheldon’s risk of suicide should have been obvious to anyone who was responsible to keep him safe. That the jury found such fundamental failings in care, training and staffing levels sends a clear warning to Government about the crisis in prisons. There have been 3 further self inflicted deaths in HMP Winchester. The Prisons Minister must account to Sheldon’s family as to what action is to be taken in response to the serious failings identified.”