A report to prevent future deaths was written by coroner David Hinchliff following the inquest into the death of Matthew Stubbs.
After hearing four weeks of evidence at Wakefield Coroner’s Court in October and November 2015, a jury had returned a neutral but lengthy narrative verdict.
They found the cause of Mr Stubbs’ death was brain injury caused by hanging and went on to detail his mental health issues as well as how prison and healthcare staff interacted with him after he arrived at HMP Leeds on July 15, 2013.
It prompted Mr Hinchliff to use his powers to detail actions which he believed should be taken by the prison and healthcare providers working there – and to require those organisations to report back.
He sought assurances that HMP Leeds had acted on 10 recommendations made by the Prisons and Probation Ombudsman in an earlier report into the death.
He raised concerns about the confusion surrounding how staff should carry out Assessment, Care in Custody & Teamwork (ACCT) observations and whether Mr Stubbs should have been moved from segregation to the health care centre, due to differing national and local policy.
Regarding healthcare, Mr Hinchliff raised concerns about one doctor’s understanding of his role in respect of segregated prisoners and urged that his involvement be reviewed.
He also highlighted a lack of communication between the different healthcare providers working with prisoners who had mental health issues, and said that it was “essential” that IT systems allow the proper sharing of records. A joint response was sent to the coroner from Leeds and York Partnership NHS Foundation Trust and Leeds Community Healthcare NHS Trust, who said they had reviewed training and the doctor involved in Matthew Stubbs’ care had retired.
They said they had worked to develop a “new seamless model for mental health care” , but a new provider took over in April 2016.
HM Prison and Probation Service failed to respond within the 56 days due to an “administrative error”.
Its response in April 2017 detailed new weekly safety intervention meetings, training and national policies.