Re: Andrew Goldstraw 

Two-week Article 2 jury inquest into the death of a man who was found hanged in his cell in prison having taken an excessive amount of anti-depressant medication and had traces of psychoactive substances in his system. He had only been on remand for three weeks at the time.

Issues: (a) the precise time of death; (b) the assessment and management of his risk of suicide; (c) failures in observations by prison staff; (d) whether he should have been allowed to have anti-depressant medication in his possession; (e) access to and impact of synthetic cannabinoid drugs on his psychological state; and (f) whether he intended to take his own life. It was concluded that he intended to take his own life and was failed by multiple bodies in with regards to the assessment and management of his risk of suicide, allowing him to keep medication in his possession and taking synthetic cannabinoid substances. These failures had a more than a minimal contribution to his cause of death. Further, the Coroner drafted a PFD Report to address the functional ability of the SystmOne computer system to allow staff to quickly and reliably identify the relevant medical history of an inmate for the purposes of a mental health (or other) risk assessment. See media here.