DM

Independent investigation into an incident of life-threatening self-harm involving ‘DM’[1] at Southampton Magistrates’ Court on 16 March 2015

The report of the independent investigation conducted by Barbara Stow into an incident of life-threatening self-harm involving ‘DM’ at Southampton Magistrates’ Court on 16 March 2015 is published here.  Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at Southampton Magistrates’ Court.

On 16 March 2015 ‘DM’ was collected from a police station by GEO Amey[2] (a private company contracted to provide escort services) and taken to Southampton Magistrates’ Court.  He was tearful and told GEO Amey staff that he was going to kill himself.  On arrival at Southampton Magistrates’ Court, he was held in the court cells and a suicide and self-harm form was opened by GEO Amey staff.  In court ‘DM’ was given a 12 week custodial sentence and was returned to the cells as a  serving prisoner.   Shortly afterwards, he was found hanging from the toilet cell gate.  An ambulance was called and ‘DM’ was taken to hospital.  ‘DM’ sustained a serious and long-term brain injury, and after four years in a nursing home and several periods in hospital, sadly died on 11 May 2019, before this investigation concluded.

In March 2015 GEO Amey conducted an internal investigation into the incident, which made a number of findings and recommendations.

In order to meet the State’s investigative obligation under Article 2 of the European Convention on Human Rights, Barbara Stow, a former Assistant Prisons Ombudsman, was commissioned to conduct an independent investigation to examine the circumstances surrounding the life-threatening self-harm involving ‘DM’ and to see what lessons can be learned. 

The investigation report completed by Barbara Stow is published, along with the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at Southampton Magistrates’ Court.

[1] A pseudonym is used to protect the identity of the individual concerned.

[2] Since the commencement of the PECS Generation 4 contract in August 2020. Serco now manage the South of England contract area.