David Clairmonte: Prevention of future deaths report (1)
26 Jun 2026 · Coroner Edward Steele · East Riding and Hull
The coroner's concerns
1. placement of personality disorder patient in prison without appropriate specialist care
“Evidence was heard in relation to the efforts undertaken by Stockton Hall Psychiatric Unit to find a suitable replacement offering for Mr [name redacted], who had a personality disorder, within an appropriate high-security setting that could provide specialist care. As a function of there not being an available placement in a personality disorder unit, Mr [name redacted] was instead placed at HMP Full Sutton.”
2. transfer of patient from psychiatric hospital to prison without adequate transition planning
“Mr [name redacted] was transferred from Stockton Hall Psychiatric Hospital, after having been there for nearly six years, to HMP Full Sutton on 9 October 2023.”
3. lack of coordinated physical health monitoring for patient with complex needs
“In his final year, Mr [name redacted] was a patient at hospitals in relation to his physical health issues, including a period of months at St James's Hospital, Leeds from 1 April 2024.”
4. inadequate management of bowel complications leading to cardiac arrest
“Mr [name redacted] final attendance at hospital was from 27 September 2024 until his date of death, 4 October 2024, at York District Hospital. Mr [name redacted] was admitted due to being very unwell and at the point of a cardiac arrest, due to the losses from his bowel that put heart under compromise.”