QUEENS BENCH DIVISION
33 Bull Street
BIRMINGHAM B4 6DS
B e f o r e :
(sitting as a High Court Judge)
| THE QUEEN
(on the application of Ms Rossana Hair)
|- and -
|HER MAJESTY'S CORONER FOR STAFFORDSHIRE (SOUTH)
(1) DR LOGAN
(2) SOUTH STAFFORDSHIRE PCT
(3) SECRETARY OF STATE FOR JUSTICE
The Defendant took no active part in the application and was not represented
Christopher Kemp (instructed by Radcliffes le Brasseur) appeared for the First Interested Party
The Second Interested Party did not appear and was not represented
Louis Browne (instructed by the Treasury Solicitor) appeared for the Third Interested Party
Hearing Dates: 29th and 30th March 2010
Crown Copyright ©
Judge Purle QC:
"IT DOESN'T MATTER THAT I'M NOT GUILTY YOUR GONNA DO WHAT YOU WANT ANYWAY BUT IF YOU THINK I'M GOING TO BE THREATENED, WOUND UP AND INTIMIDATED BY SOME BULLY FARMER ANY LONGER THEN YOUR WRONG. FOR 2½ MONTH I'VE SAT QUIETLY BEEN POLITE AND NOT GIVE YOU ANY TROUBLE EVEN THOUGH YOU'VE TRIED TO BULLY ME YOU'VE MESSED WITH MY FOOD YOU'VE HAD NIGHT GLOGGYS WISPERING SHIT AND SCRATCHING ON MY DOORS AND WINDOWS ALL NIGHT. WELL I'VE TRIED TO DO IT THE RIGHT WAY AND YOUR JUST TAKIN THE PISS AND I KNOW THIS IS ALL DOWN TO SMALLS BECAUSE HE IS THE ONE WHO IS SETTING ALL THIS BULLSHIT UP ALL I WANTED WAS TO BE LEFT ALONE. SO FROM NOW ON WHEN MY HEAD IS TELLING ME TO GO FUCKIN SICK I'M NOT EVEN GOING TO TRY A STOP MYSELF FROM NO ON I'M GOING TO BE LIKE I USED TO BE BECAUSE THEN PEOPLE USED TO LEAVE ME ALONE OR I'D BURN-SMASH-FLOOD-BARRICADE AND FIGHT EVERYDAY SO IT'S UP TO YOU SMALLS CARRY ON WITH YOUR BULLYING TACTICS OR DON'T I'M PAST CAREING ANYMORE."
"1. Are you sure David killed himself?
2. Are you sure David intended to kill himself?
3. Is it likely or unlikely that when the hanging incident occurred the balance of David's mind was disturbed?
WE FEEL THAT IT IS LIKELY THAT THE BALANCE OF DAVID'S MIND WAS DISTURBED. CONSIDERING HIS RESPONSE STATEMENT TO HIS ADJUDICATION ISSUED ON THE 8/12/06
4. Was David certified dead at about 23:00 hours on the 15/12/06 at Staffordshire General Hospital from the effect of the hanging incident at Stafford Prison on the 13/12/06?
5. Was it appropriate for the ACCT form to be closed on the 11/12/06?
WE FEEL THE ACCT FORM SHOULD NOT HAVE BEEN CLOSED AND DAVID SHOULD HAVE HAD FURTHER OBSERVATIONS. ALTHOUGH EVIDENCE SHOWS NO FURTHER CONCERN FROM MOST STAFF MEMBERS, DR GRADILLAS'S STATEMENT SUGGESTS IT IS DIFFICULT TO ASSESS HIS STATE WITHOUT FURTHER OBSERVATION.
6. Did David's move from a safer cell to segregation unit on the 12/12/06 materially contribute to his death?
YES. WE FEEL THIS FOR TWO REASONS.
THE FIRST BEING THAT STAYING IN THE SAFER CELL WOULD HAVE BEEN COMPLYING WITH HIS WISHES AND, SECONDLY IT WOULD NOT HAVE BEEN PHYSICALLY POSSIBLE – ACCORDING TO EVIDENCE – FOR HIM TO HAVE HARMED HIMSELF IN THE WAY HE DID IN THE SEG.
7. Did the policy towards and management of David's refusal to leave the Segregation unit significantly contribute to his death?
8. Did any failure by the disciplinary staff to tell health care staff of the response to adjudications by David significantly contribute to his death?
NO. THERE DOES NOT SEEM TO BE ANY EVIDENCE SUGGESTING THAT THE DISCIPLINARY STAFF WERE AWARE OF DAVID'S RESPONSE TO THE ADJUDICATIONS.
9. Was David being bullied by Prison Officers?
If yes, did this materially contribute to his death?
NO. WE DO NOT DEEM THE ADJUDICATIONS TO BE A FORM OF BULLYING. THERE IS ALSO A LACK OF EVIDENCE TO SUGGEST ANY OTHER FORMS OF BULLYING."
"No person shall be allowed to address the Coroner or the jury as to facts"