An inquest in Salisbury returned critical narrative conclusions following a two-week inquest before HM Senior Coroner Mr Ridley and a jury, inquiring into the death of Calam Atour.
Mr Atour hanged himself in Erlestoke Prison in Wiltshire on 13th May 2015. The jury recorded a conclusion of suicide and a narrative conclusion, listing five circumstances which, taken in combination, made it probable that his likelihood of suicide was inadequately addressed. These included the removal of medication without any follow-up, including not explaining the reasons and circumstances to the deceased; the failure to provide medical personnel to support the Assessment, Care in Custody & Teamwork (ACCT) review process; the failure on the day that Calam Atour died to provide increased monitoring following threats that he had made that day to take his own life; the failure to check his condition on unlocking his cell; staffing shortages and lack of co-ordination in the prison exacerbating the other problems.
The family of the deceased were represented by Stephen Simblet of Garden Court Chambers’ Inquests Team, instructed by Karen Rogers of Tuckers Solicitors.
