Coroner makes 12 suggestions following prisoner deaths

Manx Care and Home Affairs asked to look at how to prevent future deaths

The coroner of inquests has made 12 suggestions for improvement following the deaths of inmates at the Isle of Man Prison.

Graeme Cook has written to the Department of Home Affairs and Manx Care following the conclusion of two inquests which were held earlier this year.

In July a jury recorded a verdict of suicide at the inquest of Christopher Corkill who was found dead in his cell at the Jurby facility on 24 February last year.

The 46-year-old’s death came just three months after that of fellow inmate 28-year-old Craig Anderson who was found dead in his cell on 25 November 2022.

At Mr Anderson’s inquest, in April this year, a jury concluded he’d died by suicide while the balance of his mind was disturbed.

Jurors delivered a narrative verdict noting that whilst there was no neglect there had been a missed opportunity to render care that could have made a difference to the outcome.  

At the end of Mr Corkill’s inquest Coroner of Inquests Cook said he would consider making recommendations about both men’s deaths.

On 15 August he wrote to the Home Affairs and Justice Minister Jane-Poole Wilson and the Chief Executive of Manx Care Teresa Cope.

This he said was because both authorities had the power to take action to prevent future similar deaths.

Noting that ‘certain improvements’ had already been made by both the Prison and Probation Service and Manx Care he said he did not intend to consider these in his report.

Coroner of Inquests Cook said: "It is not the place of myself, as coroner of inquests, to recommend action that should be taken to prevent future similar deaths.

“Such decisions must be taken by the department and/or Manx Care but, having had the benefit of considering all the evidence with respect to the two deaths to which I have referred, it appears to me that the following may be matters that the department and/or Manx Care would wish to consider.”

The 12 suggestions he has made include:

1. Both the HMIP Report and the PPO Report make a number of recommendations and consideration should be given to all such recommendations being implemented.

2. Manx Care to have a dedicated clinical governance lead responsible for prison healthcare at the Isle of Man Prison to ensure that practice is compliant and underpinned by national guidance, legislation and evidence-based guidance.

3. Improved access to mental health professionals and mental health provision within the prison.

4. Treatments such as CBT and DBT to be provided to prisoners with appropriate needs.

5. Prison healthcare to have automatic access to prisoners’ health records on initial arrival at the prison.

6. Manx Care to ensure a medication review on each prisoner’s arrival.

7. For there to be an input from a mental health professional into the opening and closing of the now ACCT (Assessment, Care in Custody and Teamwork) process.

8. The prison officer who makes the decision to open an ACCT to be involved in the decision to close the ACCT.

9. Information contained in ACCT documents to be contained on PIMS and vice versa.

10. Peer support to always be available.

11. A trigger point for an ACCT to be when a prisoner is sentenced and constant cell observations should be in place for the first 48 hours.

12. For there to be regular inspections carried out HMIP.

The coroner has asked for a reply to his letter within 56 days setting out what, if any, action either body intends to take.

Manx Radio has invited the Department of Home Affairs and Manx Care to comment.

A statement from the DHA said: 

"The Department of Home Affairs welcomes the coroner’s recommendations and will now review and consider them alongside the ongoing actions following inspections from both His Majesty’s Inspector of Prisons and the Prisons and Probation Ombudsman. 

"Since the tragic deaths of Kaan Douglas, Craig Anderson and Christopher Corkill in custody the department has made several changes, with Manx Care, to improve the way vulnerable people are supported in prison.

"Good progress has been made on those actions to date.

"Of note is the introduction of the new ACCT system which provides a more robust approach to supporting vulnerable prisoners.

"Manx Care’s improvement plan has also made a significant difference to prisoner healthcare. 

"We offer our deepest sympathy and apologies to the families of Kaan, Craig and Christopher and hope they will be allowed to grieve in peace now the formal proceedings have concluded."

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