Finding into death of Dylan James Charlton-Smith

Contributing factors

• Failure to implement risk management plan despite S4 (self-harm history) rating
• Absence of formal mental health assessment following the distressing visit
• Misinterpretation of risk as escape risk rather than mental health risk
• Security-focused response rather than health-based response to identified distress
• Reliance on peer prisoner support rather than trained healthcare staff
• Impulsive nature of the suicide following relationship crisis during visit
• Approximately 50-minute gap between observation of distress and discovery

Coroner's recommendations

1. All prisoners assigned a psychological or psychiatric rating should be provided appropriate care in line with the risk management self-harm and suicide management policy
2. Review of protocols to ensure that when staff identify significant distress following precipitating events (such as distressing visits), formal mental health assessment by trained healthcare professionals occurs rather than reliance solely on security officer assessment
3. Consider requirement for mandatory mental health review when S4-rated prisoners experience significant relationship or family stressors
4. Review of training for correctional officers to distinguish between escape risk and self-harm/suicide risk when responding to distressed prisoners