A CORONER is to write to prison authorities to recommend improvements in procedure after a prisoner killed himself during his first night in custody.
Kirk Floyd Duboise was found hanged in his cell in Durham Prison at about 9.30pm on February 13.
Mr Duboise, 22, of Tees Street, Horden, had been remanded in custody earlier that day by magistrates at Peterlee.
An inquest at the Coroner’s Court in Crook heard Mr Duboise had a history of self-harm.
A care plan file, known as Action, Care, Custody and Teamwork (ACCT), was not opened by reception staff at the prison.
Prison officers told the inquest it was the habit at that time not to open an ACCT at reception, but to leave the decision to medical staff.
Night shift prison officer Tony Dixon said Mr Duboise appeared upset although that was not unusual for a prisoner spending his first night in custody.
Officer Dixon said he planned to check on Mr Duboise “every hour or so” during the night.
The body of Mr Duboise was discovered by a mental health nurse who went to see him to discuss other health issues he may have had.
The inquest heard there was a delay of a minute or two in calling an ambulance because the correct code word was not used over the radio to the prison’s control room.
Governor Christopher Hounslow said the procedures for opening an ACCT, and calling an ambulance, have both been reviewed following the death.
In a narrative verdict, the jury found Mr Duboise took his own life after he was not correctly assessed at the prison’s reception.
The jury found an ACCT should have been opened at reception.
Coroner Andrew Tweddle said he accepted procedures have since improved.
The coroner added: “I also accept the delay in calling an ambulance was not significant in this case. But it seems to me the policy in Durham at the time on the opening of ACCTs could also be being applied elsewhere in the prison estate. I will therefore write to the prison authorities at a national level to outline my concerns.”