18 December 2017

Before HM Mrs Caroline Beasley-Murray 
Essex Coroner’s Service
4 - 12 December 2017

The inquest into the death of Craig David Royce at HMP Chelmsford concluded on 12 December. The jury said that Craig died as a result of an accident and believed that ‘Mr Royce’s risk of self harm/suicide was not properly reviewed with appropriate precautions taken to manage the risk.’

Craig, 46, from Rochford, Essex was found hanging in his cell at HMP Chelmsford during the evening of 24 December 2016.  He died at Broomfield Hospital on 25 December 2016. 

Craig had a complex mental health history. He suffered from epilepsy and had been diagnosed with drug induced psychosis, primarily relating to his use of cannabis in the community. Craig had little engagement with the mental heath and substance misuse teams whilst at HMP Chelmsford. This was criticised by Professor Rix, an independent psychiatrist who gave evidence at the inquest.  Professor Rix considered that Craig should have been under the care of the Mental Health Team with input from the primary healthcare team, the prison’s substance misuse team and a neurologist or neuropsychiatrist.  Professor Rix also considered that Craig should have been offered substance misuse counselling with a plan put in place to manage Craig’s care that was subject to review.   None of this happened at the prison.

Whilst Craig was in prison, the jury heard evidence that he was bullied.  He was also placed on an Assessment, Care in Custody and Teamwork (ACCT) document on three occasions in September, October and December 2016.  The ACCT process is meant to help identify and care for prisoners at risk of self harm and suicide.

The last ACCT was opened on 20 December 2016, the week of his death. Craig had told the prison chaplain that he had made a ligature and tried to hang himself the previous evening. He said he did not have the courage to go through with it, but that next time he tried he would succeed.  Craig repeatedly said he wanted to kill himself and cried throughout. 

At Craig’s assessment interview on 21 December 2016, concerns were expressed regarding his mental health. He cried during the assessment. Despite his disclosures the previous day and his presentation in the assessment, he was considered to be at low risk of suicide and subject to three hourly checks during the day and hourly checks at night.  No mental health staff attended his review, and he was not referred for a mental health assessment.  The same levels of observations were maintained during a further case review on the afternoon of 24 December 2016.  At the inquest, staff conceded that they ought to have known Craig was at an imminent risk of self harm. Sadly, Craig was later found hanging in his cell during a routine check at around 8.11pm.  Although paramedics restarted Craig’s heart, he was pronounced dead at hospital on Christmas Day.

Craig’s death is one of three self inflicted deaths at HMP Chelmsford in 2016 and there has been at least one further self-inflicted death in October 2017.  Craig’s inquest also follows the damning jury conclusion in the Dean Saunders’ inquest in January 2017, which found Dean’s death at HMP Chelmsford was contributed to by neglect.  This led to Care UK, who provided healthcare at the prison, withdrawing from their contract due to resourcing issues.  Essex Partnership University NHS Foundation Trust (EPUT) is now the healthcare provider at the prison.

Janet Royce, the mother of Craig said:
‘The whole family is devastated by Craig’s death.  It was important to us that the jury recognised that his actions were a cry for help. 

I thought Craig would be safe in prison.  I feel strongly that Craig did not receive the help and care that he so desperately needed whilst at HMP Chelmsford.  The jury clearly recognised this when they returned their critical narrative conclusion.  I now hope the prison will learn from Craig’s death and make changes to ensure that this heartache does not happen to another family.’

Anna Thwaites, solicitor for the family, said:
‘Another critical jury conclusion about the care prisoners receive at HMP Chelmsford.  With prison deaths reaching epidemic levels, it is important that Craig does not become a statistic, but that lessons are learnt and change is implemented immediately.  As a civilised society, we have a duty to look after the most vulnerable people in our prison system, including those with mental health and substance misuse problems. The prison system failed both Craig and his family.’


For further information and to note your interest contact Lucy McKay at INQUEST.

INQUEST has been working with the family of Craig Royce since January 2017. The family is represented by Solicitor Anna-Louise Thwaites of Bindmans LLP and Counsel Ifeanyi Odogwu of Garden Court Chambers.

More information on the conclusion of Dean Saunders’ inquest in January 2017 here.