On 2 June 2015 | commenced an invesligalkn Inio [he dealh 0l STEWART AKINS, Ihen aged 51. The Investigalion concluded al ine end of the inquest on 3 March 2018 The ccnclusion 0l [he [nques was a naralve conclusion Tha med cal cause 0f death was Ia Extensive head injury Ib Collision by train

Tha raralve canclusion stated; "On 23.5.15 Stewant Akins was arrested on 5uspicicn of having committed [WvO CcMasic assaults He was takan to Worester Police Station, whera his detention w3S jutnonsed Throughoul Ime in custody i: was recorded that Mr; Akins repeatedly Btated nis Intenbon to end his Own Iife, and he was FrFarly vewed a3 presenting & high risk of sulcide andlor sell-ham Whan he Made his first appearance before tne Wctcester Mag strates' Couit &n 25.5.15, Ihe Coutt was not tald ofthis risk and ro applicaton wa? made IDr him ta be remanded in custody because of inat Tisk ad fcr his cwn prolecticn Later that sama having Deen released on conditional bal, he tcok his own Ille Dy plazing himself in otatrain cn a railway linz ncar Malvom Wclls CQRONER S CONCERN: During the course of the inquest the evidence revealed mattors giving risg [o concein. In My opinion there is & risk that future deaths occur unloss aclon I: laken, In tha circumstances It is my stalulory duty [0 repott to you; The MATTERS OF CONCERN a0as lallows {1} Throughout Mr, Akins' tima in Custody; entries were made On the custody reccr which rezcrded his repeatadly stated irtention to end his Cwn life. Statements t0 that elfect were racotded a5 having baen made, inter aJia, t0 Custody Setgeanl toanurse, t0 a Fcrensic Medical Examiei and to the officer in charge of tha investigatior atthe End Dl his Falice interview The view was taken that he presented & high nsk of suicidelseli-harm; {21 The cticer in charge cf tne inkestigation into the cllenccs wlh which Mr Akins was eventually charged, submilled an MG? rumand application form far coneideration by Ine Crcwn Prosccution Service, and wtha viewto bail being Ppposcd In Ihe Maglstrales' CouL In Ihal torm_she set out pkjections cn his day, tne Path will the a number of grounds including a remand jor Mr, Akins' cwn protecton However, in giving Getails substantiating tnat particular ground for cpposing bail she stated; "AKINS problem with akcchol and mental tealth; cleary & combination that doas not Mix wel AKINS spoka Qf his suffering with post (raumatic stres; disorder (PTSD) and (here Is & Fea! conrem that being charged wilh offencas and now NFA he May pose a signiicent risk to not only Ihoze he encounters; but also tQ himself It i5 fherefora requested Ihat a remand in Guatodkba sought for AKINS Own prolection {31 levidence atthe inquest was that thzsa details substantiating that ground for opposing bail ( for Mr, Akins' or protecticn were based solay on her cwn dealings with Mr. Akins, ad ncton what was recorded in tha Custody Racord_In lacl shc was nclaware cfany of the entries recorded on Ihe Custody Record and was theratare nol aware pl [nie level ol risk cl suicidexsell-hamm which those in charge cf his detenton lelt that Mr, Akins presented, She had not sougnito check the Custody Record for any such entries, nor t0 speak t0 the Custody Sergeant; nor had the Custody Sergeant anught to make her aware of guch entries (4) Becauseb was unaware cf the contents of these entries in the Custody Recotd, Ine description In MG? 0l the risk cf sulcidceelf-harm whlch Mr Akins presenled was signiticanlly dowplayed (6) In addiano lhal urcer-repartirg al risk, pricr tc the hearing In Ihe Maglstrates" Court, as infcimed by (he Senior Crown Prosecuior tnat she was considering agreeing to bai with carta n conditions Those condtcns did not address the is3ue Of risk cf suicidelself-ham, bu laccepted tnat she had not soughtto raise with tha prozecutor, IB) A diroct result of thatunder-reporting of of suicidelself-ham; and cfl Ifailure I0 raise it wnth the prcsecutor; was that the prosecutor "J5 minded [o a9 10 Io conditional ball 28 proposed No objeciicns I0 bail were raised with Ihe Maglstratas, and cond lional ball was duly granted am theretora concamed tha: rochain & communicaton appeated @ be in place 'hereby was made awaie cl Ine Tsks nighllghled In Ihe Cuslody Rerold, S0 [ha an MG7 could bp properly &d prcpared (8) The explanations for this @ppear to be eiiner: that provision Cocs not exist generally for such a chain of communicatan to be In place; cr that provis Jn does exsl; and that andoi [he Cuslody Sergeant{s) tailed to cperate In accordance vath such plovisicn ACTION shouLD BE TAKEN In my aplnlan acllon shculd be laken Io prewent future deaihs and balieve Inat You nave tne power Io lake such actcn