'Lessons will be learnt' at prison following three deaths in custody says governor

Manx Care describes them as 'sentinel events' that will change offender healthcare

A warning that this story contains information which some readers may find distressing.

It is impossible to remove all risk from the Isle of Man Prison but one death in custody is one too many. 

That’s what the prison governor has told Manx Radio following the culmination of a series of inquests into the deaths of serving prisoners.

The three men had all taken their own lives, in similar circumstances, between 2020 and 2023.  

Deaths in Custody

Last week a jury recorded a verdict of suicide at the inquest of 46-year-old Christopher Corkill.

He was found dead, in his cell at the Isle of Man Prison, on 24 February 2023.

Mr Corkill’s death followed that of fellow prisoners Craig Anderson, in 2022, and Kaan Douglas on 31 March 2020.

In May 2022, at the inquest into the death of Mr Douglas, a jury concluded the 29-year-old had died by suicide whilst the balance of his mind was affected which was contributed to by neglect.

Shortly after those court proceedings concluded the Department of Home Affairs released a statement saying:

“Deaths in custody are rare in the Isle of Man and the department takes its responsibilities under the Custody Act seriously. 

“Immediately after Kaan’s death work began to make improvements that would reduce the possibility of another family having to endure this loss. 

“The coroner has been informed of this work and the ongoing efforts to ensure that those who are in custody, at the Isle of Man Prison continue to be kept safe particularly those who are most vulnerable.”

However on 25 November 2022 Mr Anderson was found dead in his cell at the Isle of Man Prison.

The jury at the 28-year-old’s inquest, in April this year, concluded that he’d died by suicide while the balance of his mind was disturbed.

Delivering a narrative verdict jurors noted that whilst there was no neglect there had been a missed opportunity to render care that could have made a difference to the outcome.

Prisons and Probation Ombudsman

Mr Anderson’s death, and that of Mr Corkill three months later, sparked independent investigations by the Prisons and Probation Ombudsman which were instigated by the Department of Home Affairs. 

Both were started in April 2023 and the PPO reports, which are dated January 2024, were released publicly in May and July this year.

Mr Douglas’ death was not reported on as his inquest had already concluded by this time.

The PPO found that, at the time of Mr Anderson and Mr Corkill’s deaths, the prison had not made sufficient changes or responded to the learning from the death of Mr Douglas in 2020.

“We found that the learning from the internal prison investigation and subsequent coroner’s inquest did not lead to sufficient change in how the prison manages prisoners’ risk of suicide or self-harm.”

- Prisons and Probation Ombudsman

The PPO also found the management of prisoners at risk of self-harm or suicide was ‘inadequate’ and mental health provision was ‘inadequate and unsafe’ and not equivalent to what is available in the community.

There were also unsafe practices noted in relation to the issuing of medication as well as a lack of clinical governance and quality oversight dedicated to prison healthcare.

You can read the Prisons and Probation Ombudsman report for Mr Anderson HERE.

You can read the Prisons and Probation Ombudsman report for Mr Corkill HERE.

HMIP

The PPO investigation followed a separate inspection from His Majesty’s Inspectorate of Prisons which was undertaken between February and March 2023.

Again, at the request of the DHA, inspectors visited the Jurby facility where they found many ‘missed opportunities and poor systems of accountability’.

It was the first inspection since 2011 and fourteen areas of concern were identified; government was told six of these should be treated as priorities which required immediate attention.

You can read the full HMIP report HERE.

A follow-up review was conducted, between 30 April and 2 May this year, where the inspectors found ‘encouraging’ improvements with ‘good’ or ‘reasonable’ progress made against nine of the concerns.  

HMIP found that governance and oversight of many critically important areas of accountability had improved.

There had also been ‘considerable effort’ by prison leaders to improve the care of those at risk of suicide of self-harm and inspectors found individuals to be well-supported.

You can read the updated HMIP report HERE.

‘Special Measures’

The HMIP report also noted that the Prison Healthcare Team had been placed in ‘special measures’ in December 2023 following the deaths in custody.

Special measures are an internal governance mechanism designed to ensure any incident, or issue, that’s identified as ‘extremely challenging and/or high risk’ is afforded a level of attention, resource and leadership in order to facilitate positive change.

“It is deeply regrettable that they took their own lives but these are sentinel events. They lead us down a path to learn things from those events. There have been many lessons from these cases that we’ve been dealing with recently.”

– Paul Moore (Manx Care)

Paul Moore is Manx Care’s Deputy Chief Executive and Director of Nursing and Governance.

He told Manx Radio he believes as a result of the tragic deaths – and the investigations that have followed – offender healthcare will be changed permanently for the better:

Special measures for the prison healthcare team concluded in May this year.

Learning

The PPO found that the Department of Home Affairs and the Department of Health and Social Care need to support the prison governor, and Manx Care, to improve staffing levels, governance, oversight and management of risk. 

Clear protocols and guidance to support staff in undertaking their duties to improve safety is also required. 

It’s understood the Coroner of Inquests will make a number of recommendations, as part of the coronial process, following the conclusion of the inquests into the deaths of Mr Anderson and Mr Corkill.

Prisoner Governor, and Head of the Prison and Probation Service, Leroy Bonnick gave evidence at the latter.

He told the jury there was a ‘deep commitment’ to preventing further tragedies.

Mr Bonnick highlighted a number of changes and developments to policy and procedures which had been sparked by the inspections.

This included moving away from the previous 'Folder 5' system, which were opened for people at risk of self-harm or suicide, to a new one called ACCT – Assessment, Care in Custody and Teamwork - and the introduction of trauma training. 

Mr Bonnick told Manx Radio whilst improvements have already been made for the better it’s impossible to remove all risk from the prison environment:

Advice and Support

If you’ve been affected by any of the issues in this story there are details of local organisations that provide advice and support HERE.