9 September 2021

Before James Thompson, HM Assistant Coroner
County Durham & Darlington Coroner’s Court
6-9 September 2021

An inquest has concluded that the death of 18 year old Charlie Todd was misadventure, and that he did not intend to take his life. Charlie was found unresponsive on 2 September 2019 at HMP Durham. The inquest heard he was being held in the Care and Separation Unit (segregation) at the time of his death and had been transferred there just 6 hours before he was found having ligatured.

His mother describes him as, “a handsome loving boy who loved to tell a story and would put a smile on the face of anyone who met him. He was a cheeky-chappie, happy go lucky and loyal. He would do anything to help or please others with or without his struggles. He was loved and will be missed infinitely.”

Charlie had been remanded to HMP Durham in April 2019, and was awaiting sentence for burglary and motoring offences. He was also awaiting trial for a wounding matter (section 18). After his death the latter charges were dropped against others accused. Had he simply been sentenced for the outstanding offences, his sentence would have been between one to two years’ custody, possibly suspended.

On reception at HMP Durham, Charlie disclosed that he had self-harmed in the months before his arrival and had a history of depression. He was also prescribed antidepressants. However, he reported no current thoughts of suicide or self-harm, and did not at that time wish to be referred to the mental health team.          

Prison staff told the inquest they had no concerns about Charlie’s mental health, and that he presented as ‘smiley’ and ‘happy’, including in the days prior to his death. Prisoners are assigned key workers who are meant to see them weekly and get to know them. Charlie had a good relationship with his key worker, but had not seen him in seven weeks. Charlie was not being monitored for suicide or self-harm risk (under an ACCT) at the time of death.

On 2 September, Charlie was taken to the segregation unit for a disciplinary hearing regarding possession of illicit substances. He told the adjudication hearing he was holding the drugs for other prisoners, not himself, and would like to be moved to another wing. However, he pleaded guilty and was punished with loss of earnings and privileges, and five days of cellular confinement in the segregation unit.

Being segregated is known to increase a prisoner’s risk of suicide and self-harm, and prison policy states a healthcare professional must screen people within two hours of being segregated to assess their suitability and risk. On 2 September, the nurse did not undertake the required face to face assessment but made an assessment based on her previous knowledge of Charlie, because she said she did not believe he was at risk. She told the inquest this was “a mistake”.

Prison officers told the inquest that the segregation unit should have four staff, but often only had two or three and would loan staff from other wings. One officer said that “on a day to day basis, no one [was] in charge”, with senior officers only occasionally coming to the unit. Officers were required to check on people in segregation at least hourly, but told the inquest that in practice this didn’t always happen due to staffing levels.

Having arrived in segregation at 10am, Charlie was last seen by prison staff at 2.22pm as part of a roll check. Staff did not check him again until 4.05pm when they found him hanging from a ligature point. Attempts to resuscitate were unsuccessful.

The inquest heard some evidence of an apparent belief among prisoners at Durham that the way out of segregation was to self-harm to get back to the wing. The inquest also heard suggestions from Charlie’s brother that he himself had done this in another prison, after a lengthy period of segregation, and was subsequently moved – an example that Charlie was apparently aware of.

Since 2015 there have been 42 deaths of men at HMP Durham, of which 17 were reported by the prison to be self-inflicted. The most recent prison inspection in September 2018, a year before Charlie’s death, found issues with safety and a lack of action on recommendations following previous self-inflicted deaths.

The coroner is considering making a report to prevent future deaths, but has asked for further information from the prison on various aspects around checks on prisoners and emergency codes when seeking an ambulance response.

Emma Todd, Charlie’s mother, said: This week was about getting truth and justice for Charlie and our family. The prison had a duty of care and failed him massively. Like most teenagers, Charlie had his struggles and battles, sometimes making the wrong choices along the way.

Charlie will never get to make things right and live his life. There were missed checks from prison staff and a mental health nurse failed to assess him before he went to segregation. Charlie was a vulnerable young lad who we believe was targeted by other older prisoners and bullied. All of these were missed opportunities by the prison to help support and save him.

Some good has got to come from this. I’d like for significant changes to be made so no other family have to go through this nightmare. My son was 18, just a boy, with his whole life to live. Changes need to be made and fast.

I’d like to thank the few prison staff who tried to help Charlie and cared for his welfare. To the staff who found Charlie and have been affected by what they dealt with, I’d like to thank them from the bottom of my heart.

Without the help of INQUEST and Ruth Bundey, things would have been missed and evidence gone unheard. I’m truly grateful for everything they have done for me and our family.”

Jodie Anderson, senior caseworker at INQUEST who is supporting the family, said: “Too often, young people are failed by our education and social systems, and brought into the criminal justice system where they are further harmed. Charlie’s death is at the very sharpest end of these systemic issues. He was a teenager navigating an adult prison, which was unable to even fulfil their own safety policies or protect him.  

Six years ago, an independent review led by Lord Toby Harris looked in depth at the self-inflicted deaths of young people in prison and made urgent and important recommendations for change. Charlie’s death is a reminder that, despite the well-known evidence of the harms of imprisonment for young people, not enough has been done to protect their lives.”

Ruth Bundey of Harrison Bundey solicitors, who represents the family, said: “Crucial for the family was the conclusion of misadventure, showing that Charlie never intended to die. But it is a regret that the jury did not provide any further detailed findings of fact, other than those known before the inquest even began.


For further information and to note your interest please contact Lucy McKay on 020 7263 1111 or [email protected]. A photo of Charlie is available here.

Charlie’s mother is represented by INQUEST Lawyers Group member Ruth Bundey of Harrison Bundey solicitors. She is supported by INQUEST Senior Caseworker Jodie Anderson.

Other Interested persons represented are HMP Durham and Tees, Esk and Wear Valleys NHS Foundation Trust.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Changing Prisons, Saving Lives Report of the Independent Review into Self-inflicted Deaths in Custody of 18-24 year olds, known as The Harris Review, was published in July 2015 and called for “radical change” to prevent the deaths of young people in prison.

The latest statistics on deaths and self-harm in prison in England and Wales (published 29 April 2021) showed a record high of 154 deaths in prison in the past quarter, and a 42% increase in deaths in the past 12 months.