Marta Vento
11 Mar 2025 · Coroner Rachael Griffin · Dorset
The coroner's concerns
1. remand prisoner released without risk update
“The perpetrator of [the deceased]'s death was a remand prisoner at HMP Winchester between the 9th of July and the 27th of October 2020. He was released on the 27th October 2020 unexpectedly after a video link hearing before the Magistrates Court at which he was sentenced and immediately released.”
2. lack of information sharing leading to future deaths
“I am concerned that this lack of sharing of information could lead to future deaths.”
3. lack of national continuity of care guidance
“There is a lack of national guidance to assist all healthcare providers to ensure continuity of care for a prisoner with health care needs, whether physical or mental health needs, upon release from prison.”
4. limited patient information affecting care
“Evidence was given that as this would limit the information SWAST had access to about a patient in Dorset, this would impact upon the care provided to those in Dorset by SWAST which could lead to a future death”