2 July 2019

Before HM Assistant Coroner Tina Harrington
Chelmsford Coroners Court
24 - 28 June 2019

The jury returned a narrative conclusion at the inquest into the death of Rocky Stenning, finding that the failure to adequately assess his risk of self harm and suicide whilst he was at HMP Chelmsford contributed to his death. They also noted that restricting Rocky’s access to a telephone, the length of the prison sentence he received and other known triggers as identified in the Ministry of Justice’s suicide and self-harm policy, affected Rocky’s mental ill health.

Rocky, 26, died on 19 July 2018 after being found hanging in his cell at HMP Chelmsford. He had been in prison for just nine days. Rocky’s family described him as beautiful, funny and caring. Rocky had a long history of mental ill health and previous suicide attempts following the death of his father. He had been diagnosed with bipolar disorder and had periods in mental health hospitals detained under the Mental Health Act.

The inquest heard that from 28 March 2018, Rocky had been at Basildon Hospital under the Mental Health Act (section 3) due to a manic episode caused by the stress of his impending court case. His section was later rescinded but he was not discharged and remained a voluntary patient right up to his sentence. He remained in hospital throughout his criminal trial, only permitted leave to visit his family and attend court. Rocky’s family wrote letters to the judge highlighting their concerns about his mental health and the impact that prison would have. Despite this Rocky was given a nine year sentence and taken straight to HMP Chelmsford.

When Rocky entered prison on 10 July 2018, attached to his Personal Escort Record (PER) was a copy of his psychiatric report from Basildon Hospital which warned that should Rocky receive a custodial sentence, the stress of a prison setting would likely affect his mental health adversely. It also said that he should be monitored. He was seen at reception by a prison officer and mental health nurse. The jury heard that neither considered opening the prison’s suicide and self-harm monitoring procedures (an ACCT), despite the recommendations of the psychiatric report and other known risks and triggers, including that Rocky had just been transferred from a mental health hospital, had a history of mental ill health, had just received a long prison sentence, had made a previous suicide attempt and had a family history of suicide. The jury heard that all staff who saw Rocky only took his presentation into account when assessing him.

A mental health referral was made but the relevant assessment was not completed to prioritise the referral. There was also an error in Rocky’s file which restricted his access to a phone, but this was not picked up or removed and he was unable to make any phone calls to his family during his time at HMP Chelmsford.

Rocky was moved to a different wing on 19 July. Prior to his move he was interviewed and it was noted that he appeared withdrawn, overwhelmed and struggled to maintain eye contact. The jury heard evidence that again none of the risks or triggers were considered at that point and an ACCT was not opened. The prison officer stated he was unaware of the potential triggers as identified in the suicide and self-harm monitoring processes, despite having received ACCT training.

HM Assistant Coroner Tina Harrington stated she would be making a prevention of future death report in relation to the Prison Service regarding training on suicide and self-harm monitoring procedures, in particular risk assessment, and would also be writing a letter to Essex Partnership University Trust and the new healthcare providers, Castle Rock group, highlighting her concerns.

Following the conclusion of his inquest his family said: “Our brother was a loyal funny caring boy who loved his family & friends. We as a family are pleased that the jury recognised the prison’s failure to look after our brother:  for once someone as listened to us!! He will be so missed, as some would say he was too special for this world ... we are devastated truly heartbroken – he was OUR CHAMP.”

Christina Juman of Deighton Pierce Glynn who represents the family said: “Rocky’s case sadly highlights once again the reliance that staff place solely on presentation when assessing a prisoner’s risk of suicide and self-harm.  Presentation is only part of the picture, full consideration needs to be given to all of the risk factors and triggers to ensure a well-rounded understanding of a prisoner’s level of risk. The PPO has highlighted this on more than one occasion”.

Deborah Coles, Director of INQUEST said: “It is chilling that the circumstances and failures of this death are so familiar. Repeated warnings from coroners and inspection and monitoring bodies about unsafe practices at Chelmsford prison have been systematically ignored. Ultimately, responsibility for Rocky’s death rests with the complacent and indifferent response to potentially lifesaving recommendations. Without action and accountability, nothing will change.

It is time for bold and decisive action to stem the rising toll of deaths in prisons across England and Wales .Until this government properly invests in mental health provision, and stops the use of prison for people in mental health crisis, these tragic and needless deaths will continue.”


For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected]; [email protected]

Counsel Maya Sikand of Garden Court Chambers and Christina Juman of Deighton Pierce Glynn represented the family.

The other interested persons represented at the inquest were the Ministry of Justice and Essex Partnership University Trust (EPUT). EPUT no longer provide Healthcare services to HMP Chelmsford, the new provider in place is Castle Rock.

For information and advice on how to safely report on self-inflicted deaths, please look at the Samaritans Media Guidelines for reporting suicide and self-harm.

Deaths in HMP Chelmsford:

The jury found that neglect contributed to the death of Dean Saunders, 25, who died in HMP Chelmsford after being taken into custody when he was in severe mental health crisis. He died on 4 January 2016 after electrocuting himself. Media release

Dean’s death sparked the national Review of self-inflicted deaths in prison custody 2016by the Ministry of Justice (published 11 October). Mark and Donna Saunders, Dean’s parents, gave evidence to Parliament’s committee on Human Rights for their inquiry on Mental Health and Prisons.

Craig David Royce, 46, was found hanging in his cell at HMP Chelmsford on 24 December 2016 and died the following day. The jury concluded 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.’ Media release.

Since Dean died on 4 January 2016, there have been 14 further deaths at HMP Chelmsford. Of these, six were self-inflicted, four were non self-inflicted, one was drug related and three are awaiting classification.

The last inspection report by HM Inspectorate of Prisons (published in October 2018) found that too many recommendations from the Prisons and Probation Ombudsman (PPO) following deaths had not been implemented. They reported, “Perhaps the most worrying issue was how men who were at risk of suicide and self-harm were managed.”  Press release