Jury identified serious failures in relation to the death of Davy Larmcombe at HMP Lincoln 3rd December 2015 Jury return highly critical conclusion in self-inflicted prison death inquest Lester Morrill have secured a damning conclusion from the inquest into the death of Davy Larcombe, a vulnerable young man who took his own life at HMP Lincoln on 22 February this year. In delivering their conclusions the jury identified several failings, describing several as “serious”. On 13 January, Davy was unexpectedly, and without explanation, transferred from HMP Nottingham to HMP Lincoln. Unbeknownst to him, this was due to overcrowding on the vulnerable prisoners’ wing at Nottingham. Due to the distance away, Davy’s parents were not able to visit him at all in Lincoln, as Davy’s father was very ill at the time. Davy had very little money, and therefore could not afford to contact them by telephone, meaning aside from his initial phone call on arrival at Lincoln, Davy did not speak to his parents for the entire time he was there. Davy was monitored via the ACCT (Assessment, Care in Custody and Teamwork) system; however, there were numerous failings in relation to the ACCT paperwork, and the management of his risk. Davy self-harmed by cutting twice, and on each occasion referred to the distance from, and lack of contact with his family as the main cause of his low mood. Attempts were made by Custodial Managers to facilitate a transfer back to Nottingham; however, these were not actioned due to staff shortages, nor were they followed up due to deficiencies in his ACCT document. The jury characterised these as “serious” failings. Those responsible for managing Davy’s ACCT also failed to record key risk factors in the ACCT document, such as his family history of suicide and important trigger dates - again, the jury found this to be a “serious omission”. There were also several “serious failures” to pass on, or act on relevant information. Davy disclosed in an ACCT review on 17 February that he had been experiencing increased thoughts of self harm since taking Duloxetine - which he had been prescribed three weeks previously for back pain. Duloxetine can also be prescribed as an antidepressant, and it has a known side effect of increasing self-harm or suicidal ideation in the first 2-3 weeks of the prescription. No review had been scheduled to follow up Davy in relation to this risk, and no record was made in the ACCT review of his increased thoughts of self-harm, despite a note being made on the medical records by the mental health nurse who attended the review. On 21 February, Davy gave a note to a prison officer, stating that he was being pressured on the wing about debts inherited from a former cellmate, and had increased anxiety and “zero motivation”. The jury concluded that the Senior Officer on the wing, who happened to be Davy’s ACCT Case Manager, was made aware of the note, and that event if he wasn’t, he should, as case manager, have made himself aware in any event. No case review was held following receipt of this note - another “serious” failure according to the jury - and Davy took his own life that night. This is another sad case of a prison failing to adequately care for the needs of a vulnerable young man in their custody. HMP Lincoln Governor, Peter Wright, accepted in evidence that there had been failings in numerous areas and explained that he has implemented various steps in respect of the issues raised in Davy’s case. Mr Wright was present throughout the inquest, and also gave evidence that he intended to have a full staff briefing in light of the evidence that he had heard. Davy’s family were represented by INQUEST lawyers Gemma Vine and Trainee Solicitor Charles Myers who are part of the civil liberties team at Leeds based solicitors Lester Morrill and Barrister Jesse Nicholls, Doughty Street Chambers, London.