25 May 2017

Before Senior Coroner for Avon Maria Voisin

Avon Coroner’s Court, Bristol
15 – 25 May 2017

Callum Smith, 27, from Cheltenham was remanded in custody at HMP Bristol after allegedly making threats to commit criminal damage during a mental breakdown. He was discovered hanged in his cell March 2, 2016 and pronounced dead at the scene, just six days after arriving at the prison.

Callum had recently began suffering from paranoia and delusions. His partner was pregnant with the couple’s second child when he died. An inquest into his death found a series of failings, including that despite Callum self-harming and threatening to kill himself multiple times, he was not placed on a self harm and suicide prevention plan (known as ACCT).

The eight day inquest concluded today in Avon Coroner’s Court in Bristol, with the jury concluding that Callum’s death was caused by:
• Inadequate attention to the concerns of Callum’s family, his own requests for help and for communication with his family, the level of his anxiety, and acts of self harm whilst in police and prison custody.
• Failures to record key events on the Person Escort Record [which accompanied Callum from police custody to prison] and to include health and mental health records on transfer to prison.
• Inadequate communication between those involved in Callum’s care.
• An inadequate mental health assessment [in prison on 29 February 2016] and failure to carry out a timely full mental health assessment and to ensure that a proper referral took place with handover.
• Repeated failures to open an ACCT due to lack of training, inadequate training and staff understanding, failure to take responsibility for the opening of an ACCT and failures to recognise that self harm extended to Callum banging his head against a wall or a door.
• Inadequate integration between, and access to, IT systems which led to key information being missed.
• Failure to support Callum by not allowing a follow up assessment to take place.

The jury further concluded that Callum was suffering from extreme anxiety and distress when he committed suicide. The jury was asked to consider a number of issues including the adequacy of information provided to the prison by Gloucestershire Constabulary about Callum’s risk of self-harm and the implementation and adequacy of risk assessments and suicide prevention procedures at the prison.

The Senior Coroner for Avon, Maria Voisin, said that she would be sending a ‘Preventing Future Deaths’ report to the Avon and Wiltshire Mental Health Partnership NHS Trust, which provides mental health services at the prison, and Bristol Community Health, which provides detoxification services, setting out her concerns that further deaths could occur due to the quality of training for healthcare staff regarding the ACCT regime.

Libby Smith, Callum’s partner said:
“I didn’t want Callum to be arrested or for him to go to prison. I called the police because Callum was going through a crisis and we couldn’t get help anywhere else.

When he was first remanded the police told us that he would be on a psychiatric wing and would get the help that he needed. This didn’t happen. It has been very difficult to sit in court and hear witness after witness say that Callum was self-harming and threatening to kill himself but nothing was done. I really think people need to open their eyes to how we treat prisoners in this country.

After Callum was arrested there were so many opportunities for someone to step in and make sure that he was kept safe. The fact that no one did this means that my two children will now grow up without a father. Our daughter was the apple of Callum’s eye and I know that he would have been a wonderful father to our son who he never go to meet. I miss Callum every day and wish that he was still with us.”

Sandra Smith, Callum’s mother said:
“Callum was the eldest of my four children and was very much loved by his family. He struggled with drug addiction throughout his life but he never stopped trying to get better.

When he was arrested I thought that he would be looked after and would get the help he needed. You always assume that people know how to do their jobs but it has been a terrible shock to hear that so many people failed in so many ways to respond appropriately to the very obvious risk that Callum posed to himself.

I can only hope that some good will come from Callum’s death and that changes will be made to make sure that other families don’t have to suffer like we have. Prisoners are people too and they deserve to be treated with professionalism and care. It is a tragedy for our family this didn’t happen in Callum’s case.”

Deborah Coles, Director of INQUEST said:
“This is yet another case of a person urgently in need of mental health care and support who ends up in the criminal justice system. That Callum’s family had to call on the police for help after being unable to access the appropriate healthcare is an indictment of community mental health provision. As a result, Callum ended up in a struggling prison system ill-equipped to cope with his mental health needs and who failed to enact policies designed to protect at risk prisoners.

The jury conclusions highlight the importance of the police and prison service listening to families, whose input can dramatically alter the outcomes of potentially tragic situations like this one.

Callum’s death underscores the urgency of recent recommendations from the Committee Against Torture that the UK government must prioritise increasing the number of beds in psychiatric hospitals, and prison authorities must ensure that all staff are trained in mental health care and understand when to make referrals. The familiar failings to protect vulnerable prisoners only point to the urgent need for the incoming Government to act on this unacceptable death toll in prisons.”

The family is represented by INQUEST Lawyers Group members Gus Silverman of Irwin Mitchell solicitors and Ifeanyi Odogwu of Garden Court Chambers.


For further information, please contact: Lucy McKay on [email protected] or 020 7262 1111

  1. For the statement from Callum’s solicitors see: www.irwinmitchell.com/newsandmedia

    2. In 2016 there were 6 self-inflicted deaths in HMP Bristol including Callum’s, and two unclassified deaths. There was a further self-inflicted death in April 2017.

    3. Ministry of Justice (MOJ) stats show the rate of self-inflicted deaths in prison has more than doubled since 2013.

    4. In April the Council of Europe’s Committee for the Prevention of Torture published their report on UK detention. In light of their inspections and evidence of the mental health and self-inflicted death crisis in prisons, they called for:
    • Priority to be given to increasing the number of beds in psychiatric hospitals
    • Authorities to ensure that all prison staff are trained to recognise the major symptoms of mental ill-health and understand where to refer those prisoners requiring help
    • Prisoners suffering from severe mental health illnesses should be transferred to hospital immediately

    5. The Joint Committee on Human Rights recently published an interim reporton mental health and deaths in prison, including INQUEST’s recommendation on the need for an independent oversight mechanism to oversee the implementation of recommendations made following a self-inflicted death in prison. 
  2. Recent inquests exploring similar deaths in prisons include those ofDean Saundersand Steven Davidson


INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.