On 16th February 2024 I commenced an investigation into the death of Sean Higgins 45 years. The investigation concluded at the end of the inquest on 17th February 2025. The conclusion of the inquest was suicide, the medical cause of death1a Suspension

Sean Higgins had a long history of mental health issues and substance abuse. His exact diagnosis was a maƩer of differing opinion between clinicians but alternaƟve diagnoses included paranoid schizophrenia, drug induced psychosis and personality disorder for which he was prescribed anƟpsychoƟc and anƟ-anxiety medicaƟon. In 2019 he was sentenced to 12 years imprisonment and in 2021 he was transferred to HMP Rochester. Between September 2022 and August 2023 he had been placed on ACCT procedures on five previous occasions whilst at HMP Rochester aŌer concerns of self-harm were raised including aŌer making ligatures. The inquest invesƟgated the last few months of his life when he finished psychological therapy and was removed from the mental health team’s caseload. Coincident with this but not apparently because of it he started to self isolate and was managed under CSIP procedures. In December 2023 he stopped taking his medicaƟon. His mental health deteriorated. In early January 2024 an ACCT was opened when the deceased was discovered with a ligature . The ACCT remained open for the whole of January, with six reviews being held. The mental health team did not aƩend any of the reviews, although they provided a verbal contribuƟon for one which did not contain relevant informaƟon from which an accurate risk assessment could be made. The ACCT was closed without the support acƟons being completed (which included the prisoner engaging with the mental health team) and without consideraƟon of the available documentaƟon. The Custodial Manager and supervising officer on the wing who were responsible for closing the ACCT had been sent emails echoing that which was in the ongoing record that the deceased was hallucinaƟng and was talking of hanging himself which they had not read. There were mulƟple failures follow policies for both the prison and mental health staff. The deceased fashioned a ligature six days later and leŌ a note staƟng his mental health was torture. He had not received medicaƟon for 45 days and had not seen anyone from the mental health team for over two months. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) Although HMP Rochester had addressed many of the concerns raised by the PPO in advance of the inquest, evidence was given at the inquest that some officers chairing reviews did not read relevant documentation beyond the last ACCT review prior to the review taking place. Although they additionally looked at the last CSIP review where the processes were running in tandem, they did not read the ongoing record or Nomis case notes and were unable to conduct an accurate assessment of risk as a result (2) Some of the officers chairing reviews did not understand how to complete the support plan paperwork such that the ACCT was closed when some of the support plans had not started or had not been completed