Damion Anthony Andre Martin
PFD Report
Historic (No Identified Response)
Ref: 2013-0280
Coroner's Concerns (AI summary)
Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.
View full coroner's concerns
the inquest the following = concerns were highlighted by the evidence: the initial prison reception and risk assessment; the domestic nature of Mr Martin'$ alleged charges of Common Assault and Witness Intimidation against his girl friend were not identified, notwithstanding it was considered to be a known suicidal risk factor: The first officer to respond to Mr Martin did not commence CPR sine he felt out of date with his first aid_ This raised concerns that there is no refresher 'training or a of refresher training in basic life support The observation window to the w.c area of cell 5 had a restricted view which did not extend to the area of the W.c Mr Martin was found hanging: Notwithstanding documentation to the contrary, a officer upon his roll check at approximately 5.15am did not visit Mr Martin' s cell. RT3589 against being prison during from from down During " During " prison cycle prison
Iwould ask that you give consideration to these above concerns
Iwould ask that you give consideration to these above concerns
Sent To
- NOMS
- HMP Liverpool
- Rights and Responsibilities Group
Response Status
Linked responses
0 of 3
56-Day Deadline
12 Feb 2014
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 13/12/2011 Mr Andre Rebello, HM Coroner for Liverpooly opened the inquest into the death of Damion Anthony Andre Martin, who at the date his death was 36 years old. The inquest was resumed and concluded on 23/10/2013 before a jury_ The jury found the cause of death to be: la - Hanging RT3589
Thejury concluded by finding that Damion Anthony Andre Martin took his own life.
Thejury concluded by finding that Damion Anthony Andre Martin took his own life.
Circumstances of the Death
Liverpool Magistrates remanded Damion Anthony Andre Martin in custody to HMP Liverpool on 6/12/11 for alleged offences of Common Assault and Witness intimidation his partnerb Upon transfer to the prison, Mr Martin undertook initial reception and medical examination and cell share risk assessment; where it was identified that he was a first time prisoner; before placed in cell 5, landing 4 on G wing with cell mate l Mr Martin' s cell was visited several times during the role check at approximately 5.15am 11/12/11by a officer_
Action Should Be Taken
In my action should be taken to prevent future deaths and I believe that Mr John Illingworth; Governor to HMP Liverpool has the power take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.