Hodge Jones & Allen

HJA represents Kirkwood family at Inquest

 

Hodge Jones & Allen solicitors represented the family of Peter Kirkwood in an inquest into his death between 4 and 19 October 2010.

 

Mr Kirkwood hanged himself using a shoelace in his cell in C wing of Chelmsford Prison.  After considering evidence from police and prison officers, the inquest jury returned a verdict that he had taken his own life, but that he was suffering from mental health problems and the risk had not been recognised.

 

Peter Kirkwood had been arrested on 11 October 2006 for a drink-driving offence.  He was held in Clacton Police Station for two nights, and was then transferred to HMP Chelmsford on 13 October 2006.  He took his life on his first night in the prison.

 

When he arrived at the police station, he told the custody sergeant he was hearing voices, he was on medication and he had previously self harmed.  The custody sergeant decided to put him under additional scrutiny, and placed him under the Vulnerable Prisoner Policy, which meant he was checked every 30 minutes.  However, no doctor was called to see and assess Peter, and once he had sobered up, the police officers changed the level of scrutiny and Peter was checked less regularly.

 

When the custody sergeant tried to change these details on the system, he managed to create a new risk assessment document which meant the information about Peter’s mental health condition was hidden behind other documents on the screen.

 

This meant that when another officer came to complete the forms to inform other agencies about any risks in Peter’s case, he did not see the information about mental health and self harm, and this information was not passed on.  Also, in breach of police rules the officer completing this form was a Detention Officer, rather a Custody Sergeant (who should have known to check all the forms on the system).

 

Another failing by the police was the failure to take information from Peter’s sister, Sarah, who went to the police station and told the officers there that Peter was not well and needed medication.  Nobody noted this down and no-one acted on this information.

 

Assistant Chief Constable Sue Harrison of Essex Police wrote to Peter’s mother following an investigation by the police, and stated

 

“It is clear to me from the findings of this investigation that errors were made during the time Peter was in our custody and on behalf of Essex Police, I wish to express my sincere and unreserved apologies for those errors.

 

"We at Essex Police set ourselves the highest standards and we strive at all times to provide a service that meets those standards. I am very sorry that on this occasion we did not meet those high standards.

 

"I wish to assure you that lessons have been learned and steps have been taken to ensure that such mistakes do not happen again. … I would also like to express to you and your family my profound sympathy and condolences for your loss.”

 

Mr Kirkwood was transferred to Chelmsford Prison on 13 October.  The prison officers and nurses assessing Peter stated that they did not know about earlier incidents involving him at Chelmsford, where he had previously harmed himself.  There was also evidence at the inquest that Peter was placed in a cell on C Wing, rather than in the proper cells for a new prisoner on E Wing. 

 

In a statement after the inquest, his family said: “Peter was kind, generous, thoughtful, caring and very loving. He will never be forgotten.

 

“We trusted the police, prison service and the mental health team to look after Peter. They were responsible for his well-being, safety and care.

 

“We believe Peter’s death could have been avoided if the proper checks had been made, and if communication had been followed up.

 

“The family are unhappy that despite evidence of gross failure, the jury were not permitted to comment on those failures.”

 

Ed Kirton-Darling, solicitor for the family, stated:

 

“It took a long time for this case to be heard, and I am very pleased that the family finally got the result they wanted – an acknowledgement that there were failings to care for Peter.  The family argued that the failures were significant and if they had not occurred, there was a substantial chance that Peter might not have died.  The Coroner did not accept this argument, and refused to leave the jury with a broad narrative verdict.  However, the jury did make it clear in their verdict that there was a link between the failure to recognise the risk in this case and Peter’s death.

 

The family considered that the failures were relevant, and these failures included the failure to call a doctor for Peter after he told the custody sergeant he took anti-psychotic medication, he was hearing voices and he had previously attempted self harm, and the failure to properly fill out the form which goes with every prisoner and informs the court and prison of any risks.  The family also felt that the prison failed Peter because they did not recognise he had had problems previously and because of the way he was located in the prison – he did not have a cell mate and he was not located in the proper cells designed for a first night in custody (when the acknowledged risk of self harm is highest).”

 

The family are now considering a civil claim against the police and prison service, and Ed will be advising them further about this.