17th May 2013

Monday 20 May 2013 at 10am, for four weeks
Before Deputy Coroner Anthony Eastwood
Sitting at Middlesbrough Coroner’s Court, at Teeside Magistrate’s Court, Victoria Square, Middlesbrough TS1 2AS

Andrew Hall was 41 years old when he died on the 27 March 2009 after being found with a wound to his throat in the Health Care Unit at HMP Holme House. Andrew had been placed in a cell with CCTV monitoring but was not subject to the prison’s self harm monitoring procedures when he died.

Andrew was sentenced to 4 and a half years imprisonment on 18 April 2008 at Newcastle Crown Court. He served the first part of his sentence at HMP Kirklevington where he was soon to be considered for day release. Whilst in custody, Andrew developed mental health difficulties, including experiencing episodes of paranoia and psychosis.

On 18 February 2009, Andrew cut his wrists and was taken to hospital. Andrew revealed that he believed that people wanted to hurt him.  An ACCT (Assessment, Care in Custody, and Teamwork – the system used for prisoners who are at risk of self harm) was opened while in hospital.

On 20 February 2009, Andrew was transferred to HMP Holme House, where there was a 24 hour Health Care Unit he could be moved to. Andrew continued to show signs of paranoia but was moved to normal location on 8 March.  On 19 March his ACCT was closed. A required post-closure ACCT review on 26 March 2009 did not take place.

Andrew was referred to the mental health in-reach team and was assessed by a psychiatrist. On the 23 March 2009 the psychiatrist recorded that Andrew was psychotic and a significant risk of harm to himself. No ACCT was opened despite this assessment but Andrew was moved to a camera cell in the Health Care Unit in case he needed to be monitored.  No recommendations were communicated to staff about the level of observations they needed to make.

Andrew’s family communicated their concerns about his increasing distress to the prison, however, on 27 March 2009 Andrew killed himself by cutting his throat with a piece of glass.

Andrew’s family have waited over 4 years for his inquest to take place. A previous inquest into his death in October 2012 was halted after 7 days when it became apparent that a substantial amount of evidence had not been disclosed.

Since Andrew’s death there have been 5 other self inflicted deaths in HMP Holme House.

Andrew’s family hope that the inquest will address the following issues:

  • The care given to Andrew at HMP Holme House;
  • The ACCT process assessments of Andrew’s of risk of suicide and recognition of self harming behaviour;
  • How the prison dealt with Andrew’s mental health condition and the medication he had been prescribed;
  • How staff reacted to the family’s concerns relating to Andrew’s risk of suicide;
  • The adequacy of the camera cell and monitoring systems.

Andrew’s Partner, Paula Davidson, says:

"We have waited over four years now to get answers to questions to help us understand how Andrew died. Our little girl was 3 years old when Andrew tragically died. She is now 7 years old. There have been so many milestones in her life that Andrew has missed. She often asks how Daddy died, to which I do not have any answers. I have kept up the fight so that one day we can understand the truth of what happened that day and so Andrew can rest in peace.”

Deborah Coles, co-director of INQUEST said:

“This is a tragic and disturbing death that raises serious questions about the way that HMP Holme House looks after prisoners with serious mental health issues.  There have been five self-inflicted deaths there since Andrew Hall died in March 2009. This is extremely worrying.

“This inquest has been subject to an unacceptable level of delay, causing even more trauma for Andrew Hall’s family. The fact that this delay has been in part caused by a failure to reveal documents to the family is inexcusable.”

The family is represented at the inquest by INQUEST Lawyers Group members Fiona Borrill and Imogen Hamblin from Lester Morrill solicitors and barrister Sean Horstead of Garden Court Chambers.