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