On 8lh February 2017 , commenced an investigation into the death of Margaret Atkinson: The investigation concluded at the end of the inquest on 19h January 2017_ The jury concluded that it was not reasonable for staff not to have gone into her cell earlier
i.e. that they should have gone into the cell earlier: The conclusion was "Margaret killed herself but at the time she did s0 her intention is unclear:'

The deceased had a long history of mental health illness. She received considerable mental health services input during her periods of imprisonment at HMP Low Newton: She was regularly seen with items, sometimes articles of clothing or curtains around her neck with such items at times described as "ligatures" . She was on an ACCT at the time of her death: She was not on, and never had been on, a constant watch: Mental health staff assessed her; including a Consultant Psychiatrist as low risk of suicide: She was located in the Prison's healthcare wing: On the night of 24"h January 2016, two senior prison officers and an experienced nurse saw her in her single cell with an article of clothing around her neck: talked with the deceased and asked her to remove the item of clothing from around her neck but she declined to do sO. None of the three members of staff thought this to be a high-risk situation and none thought it appropriate to enter the cell on an emergency basis. After staff had observed her in this position on at least three occasions over quite an extended period of time, staff decided to enter the cell to remove the article of clothing; but still not believing the situation to be serious: were talking to her as entered the cell expecting her to respond: The clothing around her neck was easily removed and at that time, staff became concerned and found the deceased to be unresponsive. CPR was attempted: Paramedics found her in a state of cardiac arrest but were able t0 restart the heart: She was taken t0 a local hospital but did not regain consciousness and died on 02.02.2016. The jury found that it was not reasonable for staff not to have entered earlier than they did, i.e. they should have entered the cell earlier. The evidence indicated lack of clarity in the words used to describe the articles around the deceased s neck at various times and this made the assessment of risk more difficult: As a result; of the fact that this became common behaviour perhaps was at least in part; a reason for the jury concluding that there was an inappropriate assessment of risk, which led to a in staff entering her cell in the night in question. Also, giving the deceased"s behaviour over a period of time, there was a miss-assessment of risk particularly bearing in mind that staff knew the deceased s behaviour could be predictably unpredictable and that she could act impulsively without a full appreciation ol the risks and consequences of her actions being They They they delay

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action: Your RESPONSE You are under & duty to respond to this report within 56 days of the date of this report, namely by 28ih March 2017. !, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed.