Sitting before HM Deputy Coroner for Leeds, David Hinchliffe and a Jury. The inquest into the death of Paul Clarkson at HMP Leeds on 6 July 2006, following his recall on licence, concluded on Wednesday 18 November 2009 with the jury deciding that the medical cause of his death was hanging.
In their damning narrative verdict the jury found that:
"While Paul was adequately assessed on his reception at Her Majesty's Prison, Leeds, on his recall from licence, he was provided with inadequate ongoing care and support by the Mental Health Inreach Team. The effect of the delay in Paul's core medical records arriving in Leeds contributed to the inadequate care and support, but a more thorough follow-up could have been carried out, even without access to the records. The Prison Staff did not receive adequate information about Paul's mental health history from the Mental Health Inreach Team. The Probation Services gave Paul conflicting information about his release date. There was a long delay in Paul's release and recall pack being produced by the Release and Recall Section. The Legal Services Department at Her Majesty's Prison, Leeds, did not work in accordance with Prison Service Order 6000 in respect of splitting the recall pack and delivering it to the deceased in a timely manner. Paul's solicitor gave him the correct information but was waiting for confirmation of Paul's release date. Paul was unable to speak to his Solicitor on 5 July 2006. Neither the Legal Services Department of Her Majesty's Prison, Leeds, nor the Probation Service had received adequate training in calculating release dates for prisoners recalled subject to the 1991 Criminal Justice Act. In addition, the systems at Her Majesty's Prison, leeds, were inadequate for recording and conveying information about release dates for these prisoners. While we are conscious of the need to preserve potential evidence it is both disrespectful and a breach of Prison Service Order 2700 to leave a prisoner suspended from a ligature.
Paul Clarkson's family was represented by Fiona Borrill of Lester Morrill Solicitors and Kirsten Heaven of Garden Court Chambers.