Robert McLoughlin
PFD Report
Historic (No Identified Response)
Ref: 2018-0320
Coroner's Concerns (AI summary)
The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.
View full coroner's concerns
(1) The staffing levels at HMP Leeds were very low. On the evening of the 19th February 2016 when Mr McLoughlin self-harmed there was one Officer Support Grade on his
Sent To
- HMPPS
Response Status
Linked responses
0 of 1
56-Day Deadline
21 Apr 2019
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 the 26th February 2016 commenced an Investigation into the death of Robert Scott McLoughlin; aged 32. The Investigation concluded at the end of the Inquest on 12t October 2018. conclusion of the Inquest was Misadventure. The medical cause of death was 1(a) Hypoxic brain injury, 1(b) Hanging; (2) Bronchopneumonia.
Circumstances of the Death
At the time of his death the deceased was an inmate at HMP Leeds He arrived on the 15th February 2016. Upon arrival an ACCT was opened. On the 20" February 2016 he was found suspended by a ligature: He was taken to General Infirmary, Great George Street; Leeds where notwithstanding treatment he died on the 25" February 2016. The Jury found that there were errors or omissions in respect of his various aspects of his care. The were of the view that it was possible that the death would have been prevented had these errors or omissions not occurred_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.