Peter Lawrence
PFD Report
Historic (No Identified Response)
Ref: 2016-0314
Coroner's Concerns (AI summary)
The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with limited background information.
View full coroner's concerns
(1) The inquest heard a great deal of evidence relating to the process for identifying, managing and recording risk at the first point of contact between new prisoners and prison/healthcare staff. Mr Lawrence had not been in prison before and there was very Iittle background information available to enable staff to identify less obvious risk factors , particularly in relation to the nature of the alleged offences. It was accepted in evidence that it was of particular importance at the initial screening to identify risk by other means and to record any observations in a comprehensive manner for future reference_
Part of a Series
3 separate reports were issued from this inquest, each sent to different organisations.
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2019-0245
Sent to: Walsall Mental Health Partnership; Walsall Metropolitan Borough Council;All responded
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2023-0130
Sent to: Spire HospitalNo responses yet
This report (2016-0314) is shown above.
Sent To
- National Offender Management Service
Response Status
Linked responses
0 of 1
56-Day Deadline
25 Oct 2016
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
In February 2014 commenced an investigation into the death of Peter Lawrence. The investigation concluded at the end of the inquest on 08.07.16. The conclusion of the inquest was that Mr Lawrence suffered a self inflicted stab wound to the heart: The conclusion of the jury was that Mr Lawrence was a determination of suicide_
Circumstances of the Death
Mr Lawrence was remanded into custody at HMP Peterborough on 06.12.14 charged with serious sexual offences. On 02.02.15 he was found slumped in a toilet cubicle in a prison workshop having stabbed himself with a chisel. He was treated and taken to hospital where death was confirmed:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths believe your organisation has the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.