9th April 2015

In the Stafford Coroner’s Court, The Council Chamber,County Buildings,Martin Street, Stafford before Senior Coroner Mr Andrew Haigh.

13 April 2015 (the inquest is expected to last for 1 week.)

 Mark Groombridge died from head  injuries on 27 December 2013,  after he jumped off his bed at HMP Dovegate – a privately run prison operated by Serco.


Mark had been released from prison on licence in January 2013 but his wife, Jackie became concerned about his mental health and signs of paranoia and informed the probation service about this.  Mark took a life threatening overdose and after remaining in hospital for several days in a coma, was admitted as a voluntary patient to Brockton Acute Admission Locked Ward in St George’s Hospital in Stratford. It was made clear to Mark that should he attempt to leave, he would be detained under the Mental Health Act, and this information was conveyed to Mark’s Probation Officer. A full psychiatric assessment was planned to take place on Monday the 16th of December 2013 and Mark was placed under enhanced observations.


Despite Mark’s secure detention and psychiatric needs, the Probation Service issued recall papers, apparently without making clear that a recall should only be activated were he to leave hospital. Recall papers were passed to the police, who attended Brockton Ward without warning of the reasons for their visit on the morning of Saturday the 14th of December 2013. The on call consultant psychiatrist was telephoned but no response was received as the individual was on sick leave and a locum had not been identified for that day. Ward staff formed the view, without a medical assessment of Mark’s fitness to be discharged being made, that they had no choice but to allow him to be removed by police.


Whilst in Dovegate Prison, Mark was made subject to an ACCT (Assessment, Care in Custody and Teamwork) and had meetings with both primary and secondary mental health care staff, though by the time of his death had not been assessed by a psychiatrist. On the 22nd of December 2013 he inflicted deep lacerations to his hand and foot telling staff that he wanted to die. Whilst he later claimed that the injuries were accidental, on the 25th of December 2013 he admitted that both his overdose on the 7th of December 2013 and the self-inflicted lacerations on the 22nd of December 2013 had indeed been attempts at suicide. By this time Mark was situated in the hospital wing at Dovegate and on constant observations.


A security officer was allocated the task of observing Mark on the morning of the 27th of December 2013. She had no ACCT training or experience in such supervision. Her observations of him shortly before he died were through a hatch in a locked cell door. She observed that he appeared agitated in contrast to his behaviour earlier that morning. He then climbed onto his bed and jumped off head first, fracturing his skull.


The main concern of the family is why Mark was ever removed from Brockton Ward in the first place where he could be closely observed at arm’s length and where there was every opportunity to treat him with psychotropic medication, if necessary against his wishes. Medication and arm’s length observation would in combination have been far more likely to reduce the risk of further suicide attempts than was possible in a prison environment.


Deborah Coles, co-director of INQUEST said:


“The obvious question in this inquest is regarding the absurdity of the decision to remove someone from a secure mental health unit within days of him taking an overdose and placing him in the care of the prison service which is by definition less able to cope with serious mental illness and risk of suicide.”


INQUEST has been working with the family Mark Groombridge since July 2014.  The family is represented by INQUEST lawyers Group member Ruth Bundey from Harrison Bundey Solicitors.




Notes to editors:


For further information please contact Selen Cavcav on 0207 263 1111 or [email protected]