Carl Langdell
PFD Report
Partially Responded
Ref: 2022-0331
Coroner's Concerns (AI summary)
A patient with chronic suicide risk was observed deteriorating after refusing medication. There is a systemic concern regarding items prisoners can possess in their cells overnight, and a national proposal is underway to remove identified risks.
View full coroner's concerns
(1)
(2) He had been identified by a consultant psychiatrist as at "chronic risk of suicide attempts/self-harm attempts which is likely to remain due to the nature of his personality disorder".
(3) In January 2021 he was observed to be acting in a bizarre and agitated manner after refusing his prescribed medication for the previous month. rules at HMP Wakefield to be in possession when alone in his locked cell overnight. (5)
(6)
(7) Evidence was taken at the inquest from a Governor who indicated a national proposal had been made
. If implemented this plan would remove one obvious risk.
(2) He had been identified by a consultant psychiatrist as at "chronic risk of suicide attempts/self-harm attempts which is likely to remain due to the nature of his personality disorder".
(3) In January 2021 he was observed to be acting in a bizarre and agitated manner after refusing his prescribed medication for the previous month. rules at HMP Wakefield to be in possession when alone in his locked cell overnight. (5)
(6)
(7) Evidence was taken at the inquest from a Governor who indicated a national proposal had been made
. If implemented this plan would remove one obvious risk.
Responses
Action Planned
HM Prison and Probation Services conducted pilots across the prison estate, testing alternatives to the current wet shave provision, to be evaluated in Spring 2023. (AI summary)
HM Prison and Probation Services conducted pilots across the prison estate, testing alternatives to the current wet shave provision, to be evaluated in Spring 2023. (AI summary)
View full response
Dear Mr McLoughlin,
Thank you for your Regulation 28 report of 21 October 2022, addressed to the Governor of HMP Wakefield and the Secretary of State for 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 Langdell’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.
Following evidence heard at the inquest, you expressed concerns regarding the provision of to prisoners. Thank you for bringing your concern to my attention.
You will be aware that HMPPS uses the Assessment, Care in Custody and Teamwork (ACCT) case management approach to support people at risk of self-harm and suicide. ACCT is a tool that assists staff in providing multi-disciplinary care and support to individuals at risk of harm to themselves, in order to minimise that risk.
are issued to prisoners to enable personal hygiene and care in accordance with Prison Service Instruction 75/2011 Residential Services. Control measures are in place through the ACCT process to ensure reasonable management of these items where risks are raised.
During the inquest, you heard evidence that following Mr Langdell’s death, the Governor ordered a review of the prison’s local policy and confirmed that it sets out the action that must be taken when staff issue prison , which includes a risk assessment and staff ensuring they check that the blades are present when the razor is returned.
At a national level, we recognise the risks associated with the current
provision and are actively seeking to identify improvements to the current provision. Throughout this year we have conducted several pilots across the prison estate, testing alternatives to the current wet shave provision and control measures in establishments. These pilots are due to conclude in the spring of 2023, at which time they will be evaluated
to consider any concerns or issues which may have arisen and measured against the impact they have had on violence and self-harm. This evaluation will enable us to make informed recommendations on future shaving provision in prison establishments.
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.
Director General of Prisons
Thank you for your Regulation 28 report of 21 October 2022, addressed to the Governor of HMP Wakefield and the Secretary of State for 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 Langdell’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.
Following evidence heard at the inquest, you expressed concerns regarding the provision of to prisoners. Thank you for bringing your concern to my attention.
You will be aware that HMPPS uses the Assessment, Care in Custody and Teamwork (ACCT) case management approach to support people at risk of self-harm and suicide. ACCT is a tool that assists staff in providing multi-disciplinary care and support to individuals at risk of harm to themselves, in order to minimise that risk.
are issued to prisoners to enable personal hygiene and care in accordance with Prison Service Instruction 75/2011 Residential Services. Control measures are in place through the ACCT process to ensure reasonable management of these items where risks are raised.
During the inquest, you heard evidence that following Mr Langdell’s death, the Governor ordered a review of the prison’s local policy and confirmed that it sets out the action that must be taken when staff issue prison , which includes a risk assessment and staff ensuring they check that the blades are present when the razor is returned.
At a national level, we recognise the risks associated with the current
provision and are actively seeking to identify improvements to the current provision. Throughout this year we have conducted several pilots across the prison estate, testing alternatives to the current wet shave provision and control measures in establishments. These pilots are due to conclude in the spring of 2023, at which time they will be evaluated
to consider any concerns or issues which may have arisen and measured against the impact they have had on violence and self-harm. This evaluation will enable us to make informed recommendations on future shaving provision in prison establishments.
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.
Director General of Prisons
Sent To
- HMP Wakefield
- Ministry of Justice
Response Status
Linked responses
1 of 2
56-Day Deadline
16 Dec 2022
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 26 February 2021 I commenced an investigation into the death of Carl Shaun Langdell, aged 31. The investigation concluded at the end of the Inquest on 21 October 2022. The conclusion of the Inquest was a narrative recording that death was attributable to haemorrhage from neck incision, and made findings in relation to Mr Langdell's management by the prison authorities and healthcare provider, along with a finding of suicide.
Circumstances of the Death
On 11 February 2021 around 00.05 Carl Shaun Langdell was discovered in his locked, single occupancy cell with a significant wound to his neck. He was still able to speak
Despite emergency treatment he went into cardiac arrest. He was certified dead at 01:47 on Thursday 11 February 2021 at Pinderfields Hospital, Wakefield.
Despite emergency treatment he went into cardiac arrest. He was certified dead at 01:47 on Thursday 11 February 2021 at Pinderfields Hospital, Wakefield.
Copies Sent To
2. Practice Plus Group
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.