Coroner warns of 'systemic' failings after Doncaster prisoner is found hanged

Daniel Akam, aged 43, was found dead in his cell at HMP Lindholme on October 13, 2018.

An inquest concluded he had taken his own life but that the failure to adequately review his safeguarding arrangements may have contributed to his death.

Assistant coroner Georgina Gibbs has now written to the prison’s governor and HM Inspector of Prisons, among others, warning that failings identified during the inquest could lead to further deaths.

In a Regulation 28 Report, published this week, she describes how Mr Akam had a history of depression and self harm before he was in prison and had experienced a ‘low mood and anxiety’ behind bars.

Just over a week before his death, he told how he was receiving threats from other inmates and suffering acute anxiety.

An ACCT (Assessment, Care in Custody and Teamwork) review was opened and he was moved to a different wing on October 8.

Three days before his death, he self-harmed and was placed under twice-hourly observations.

A third ACCT review took place the day before he died but this lasted no longer than seven minutes, no member of the health care team was present and the assessment wrongly concluded he posed a risk of harm to others rather than to himself.

Mr Akam was last seen alive at around 8.45am on October 13 and the next observation was missed before he was found unresponsive at 9.45am and pronounced dead soon after.

Ms Gibson said CCTV evidence showed 18 observations had been missed yet were recorded as being carried out, with five different prison officers having apparently signed those false entries.

“The fact that the five separate officers did not carry out observations, when they recorded that they did, indicates that the problem is systemic,” she wrote.

The coroner, who also described how there was a lack of training for officers about safeguarding vulnerable prisoners, added: “In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.”

The Star has contacted the Ministry of Justice, which has yet to respond.