On 3 February 2015 in the Worcestershire Coroners' Court at Stourport-on-Severn, a jury in an Article 2 inquest concluded that Paul Malicus Coley, a 44-year-old father of five and grandfather of three, “died as a result of suicide”.
Mr Coley, who had a history of self-harm and previous attempts at suicide, was imprisoned at HMP Hewell on 5 December 2013. Immediately prior to this, Mr Coley had been in custody at HMP Birmingham, where he had been placed on an Assessment, Care in Custody and Teamwork (ACCT) document to assess and monitor risk of harm.
Despite Mr Coley’s history, a new ACCT was only opened at HMP Hewell on 12 December 2013, following an incident of self-harm.
During Mr Coley’s time at HMP Hewell, he raised concerns about his medication, dietary needs, physical pain, mental health and lack of support with medical and prison staff. Mr Coley also reported thoughts of self-harm and suicide, including writing a letter setting out his plans for death, which was passed to prison staff.
Following the letter, a Threshold Assessment Grid (TAG) mental health referral was completed for Mr Coley on 16 December 2013.
Over a series of ACCT reviews, many of which took place without any healthcare staff being present, the frequency of observations of Mr Coley was reduced.
The last ACCT review was said to have taken place on 26 December 2013, with just one prison officer and Mr Coley being present. The records gave the appearance that more than one prison officer had attended the review but this was later accepted not to be the case and the officer was disciplined. According to the ACCT documentation, the time given for the review was exactly the same time as another officer observed Mr Coley in his cell.
On 31 December 2013, Mr Coley had an appointment in relation to the TAG referral. However, the mental health nurse who saw Mr Coley said that she had not read any of the documentation and did not know the purpose of the appointment. The appointment was cut short so that Mr Coley could be returned to his cell for ‘lunchtime lock-up’.
Later that evening, when just one member of staff was working on Houseblock 1 where Mr Coley was situated, Mr Coley was observed in his cell, apparently leaning against the cupboard.
When the member of staff realised Mr Coley had a ligature round his neck, he did not enter the cell but attempted to radio a ‘Code Blue’ for assistance. However, his radio was not working and he had to make a telephone call instead.
The healthcare staff had difficulty in reaching Mr Coley, due to procedures in place at the time preventing them from entering the unit without a prison officer and the ambulance was delayed in getting to Mr Coley, again due to security procedures in place at the time.
Following unsuccessful attempts at resuscitation, at 21:56 on 31 December 2013, Mr Coley was pronounced dead in his cell.
The jury found that Mr Coley died due to hanging. They concluded in the Record of Inquest:
“Mr Coley died as a result of suicide. Contributing factors were inadequate and inconsistent risk assessments in accordance with ACCT (Assessment, Care in Custody and Teamwork) guidelines, failings in a multi-disciplinary approach and insufficient communication.”
A number of changes have since been made at HMP Hewell, directly as a result of Mr Coley’s death and concerns raised by his family about systems in place at the prison.
Mr Coley’s family said:
“Paul loved entertaining us all with his lyrical rhymes. Despite his inner struggles with depression he blazed into our lives like a shooting star and unfortunately left us just as rapidly. He loved his children; they were his life. He will be sorely missed by all of us.”
Some members of Mr Coley’s family represented themselves at the inquest. This case, and its outcome, demonstrates the importance of representation for bereaved families in complex inquest proceedings, particularly when the death in question occurred in custody.
Media coverage of the inquest can be found via the BBC and the Express and Star: ‘Wolverhampton inmate disclosed suicidal thoughts before ending his life, inquest hears’ and “Flat battery meant prison officer couldn’t make emergency call when he found a hanged inmate.’ An interview with instructing solicitor Cormac McDonough on BBC Radio Hereford and Worcester provides further information (please listen 01:47:30 to locate the interview).
Two of Mr Coley’s children were represented by Una Morris, who was instructed by Cormac McDonough, Hodge Jones & Allen. Both are members of INQUEST Lawyers Group.
Una Morris is a member of the Garden Court Chambers Inquests Team.
