Craig Steadman
PFD Report
Partially Responded
Ref: 2024-0442
Coroner's Concerns (AI summary)
Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing recommendations from being fully acted upon.
View full coroner's concerns
There were several investigations into Craig Steadman’s death including a post incident review by HMP Winchester, the PPO,and the prison healthcare provider. Various recommendations flowed from the above. However upon questioning of various members of staff called to give evidence at the Inquest it became clear that several of them were not aware of the findings of the investigations nor the recommendations. The reports had not been shared with staff directly involved with Craig during his recent time in custody. It is not possible for learning to be fully disseminated and acted upon if there is no process for sharing the findings of those organisations tasked with investigating deaths in custody and discussing these with the relevant Prison/Healthcare staff.
Responses
Action Taken
HMP Winchester shared and discussed the investigation report with relevant staff, and the Head of Safety will now routinely share reports and learning points. Recommendations are also used to produce national learning bulletins across the prison estate. (AI summary)
HMP Winchester shared and discussed the investigation report with relevant staff, and the Head of Safety will now routinely share reports and learning points. Recommendations are also used to produce national learning bulletins across the prison estate. (AI summary)
View full response
Dear Ms Rhodes-Kemp,
Thank you for your Regulation 28 report of 8 August 2024, addressed to the Ministry of Justice. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.
I know that you will share a copy of this response with Mr Steadman’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have expressed concerns regarding the process for sharing findings and recommendations resulting from investigations into deaths in custody.
I have received assurances from the Governor at HMP Winchester that the investigation report into the death of Mr Steadman has now been shared and discussed with the relevant staff. Going forward, once an investigation report into the circumstances of a death in custody is received, the Head of Safety will identify the relevant members of staff and discuss the findings with them. This will include sharing the report, highlighting any areas of learning and ensuring that the member of staff understands the content. Additionally, any learning identified that concerns the prison more generally will be acted upon at an early stage, ensuring effective changes are made. This will include liaising with other agencies, such as the healthcare provider.
At a national level, all recommendations made following an investigation into a death in custody are considered by the national learning team and are used to produce learning bulletins that are shared across the wider prison estate.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
Thank you for your Regulation 28 report of 8 August 2024, addressed to the Ministry of Justice. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.
I know that you will share a copy of this response with Mr Steadman’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have expressed concerns regarding the process for sharing findings and recommendations resulting from investigations into deaths in custody.
I have received assurances from the Governor at HMP Winchester that the investigation report into the death of Mr Steadman has now been shared and discussed with the relevant staff. Going forward, once an investigation report into the circumstances of a death in custody is received, the Head of Safety will identify the relevant members of staff and discuss the findings with them. This will include sharing the report, highlighting any areas of learning and ensuring that the member of staff understands the content. Additionally, any learning identified that concerns the prison more generally will be acted upon at an early stage, ensuring effective changes are made. This will include liaising with other agencies, such as the healthcare provider.
At a national level, all recommendations made following an investigation into a death in custody are considered by the national learning team and are used to produce learning bulletins that are shared across the wider prison estate.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
Sent To
- HMP Winchester
- Practice Plus Group
Response Status
Linked responses
1 of 3
56-Day Deadline
7 Oct 2024
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 7th March 2020 an investigation commenced into the death of Craig Steadman aged 32 years. The investigation concluded at the end of the inquest on 1st August 2024. The conclusion of the Jury at Inquest was Medical Cause of death 1a.Ligature Suspension and
2.Mental Illness NARRATIVE CONCLUSION Mr Steadman died by suicide at 01:25 on the 27/02/2022 in cell D36 at 3, West Hill, Romsey Road, Winchester. A probable contributing factor was the extended lock up due to the covid regime and staff shortages meaning that Mr Steadman had not left his cell at all on 26/02/2022. A possible contributing factor was the inadequate implementation of the ACCT process on 26/02/2022
2.Mental Illness NARRATIVE CONCLUSION Mr Steadman died by suicide at 01:25 on the 27/02/2022 in cell D36 at 3, West Hill, Romsey Road, Winchester. A probable contributing factor was the extended lock up due to the covid regime and staff shortages meaning that Mr Steadman had not left his cell at all on 26/02/2022. A possible contributing factor was the inadequate implementation of the ACCT process on 26/02/2022
Circumstances of the Death
In January 2020 Craig Steadman was released from Custody on Licence but a week later he breached a condition and was remanded back to HMP Winchester on 13th January. He had Diabetes and a mental health history, was on a weekly anti psychotic injection plus a history of multiple self harming incidents including overdosing on . After being assessed as suitable to hold his own medication he overdosed on on 17th January 2020 and was placed on an ACCT which was closed again on 18th January. He struggled with the Covid Lock Down restrictions and lack of contact with his family. On 26th February he self harmed, cutting himself , and the ACCT was reopened. At 00:44 he was found suspended by a ligature . CPR by staff then paramedics proved futile and he was sadly pronounced deceased at 01:25 on 27th February 2020.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.