Failure to hold urgent suicide risk review probably contributed to 33-year-old's death in prison, jury concludes

Returning a narrative conclusion, a jury found that that an urgent multi-disciplinary review of Craig’s risk of self-harm and suicide should have taken place on the day he died, and that the failure to hold that review probably contributed more than minimally to his death. 

The jury also found that a failure to increase Craig’s observations by prison staff on the day he died may possibly have contributed more than minimally to his death.

An inquest into Craig’s death was held at Exeter Coroner’s Court from 1 to 15 September 2026. 

HM Area Coroner for Devon, Plymouth and Torbay, Deborah Archer previously ruled that Article 2 was engaged, and that the inquest would examine whether the state failed in its duty to protect Craig’s right to life.

The inquest examined how Craig’s risk of self-harm and suicide was managed in the seven weeks he was at HMP Exeter after he was remanded and charged with driving offences on 5 September 2022.  

The inquest heard that Craig had complex needs, including ADHD, autism spectrum disorder, PTSD, a personality disorder and a history of self-harm and suicide attempts. Craig was an impulsive self-harmer and had previously attempted to take his own life in prison.  

Craig began to receive support under the prison’s Assessment, Care in Custody and Teamwork (ACCT) process after an episode of self-harm on 1 October 2022, and following a phone call with his former partner. He was subsequently placed on ACCT observations, meaning that prison staff would check on him a certain number of times each day and night.

Over the following weeks, the inquest heard Craig repeatedly self-harmed and expressed suicidal thoughts. He also told staff that he felt threatened by other prisoners.  

The inquest heard about repeated failures to record and share important information about Craig’s risk. Information about episodes of self-harm, suicidal statements and conversations with staff across different disciplines was not consistently recorded in his ACCT document.

Craig had four ACCT case reviews with four different case coordinators, meaning that no one person had an overview of his risks and triggers.

The inquest heard that on 26 October 2022, Craig told a member of healthcare staff that he had tried to take his own life the night before and that it was only the fact that he had woken his cellmate that had prevented him from following through. He also said that he had nothing to live for. The healthcare staff member described a significant deterioration in Craig’s mental health during the day on 26 October 2022.

Two supervising officers subsequently spoke to Craig, but despite his earlier disclosure, his level of ACCT observations was not increased, nor was his cell checked for potential means of self-harm. The inquest heard evidence from the supervising officer leading the discussion that he could not remember being made aware of Craig having attempted to take his own life the night before.

Later that evening, Craig made calls to his former partner in which he said that he would take his own life. Subsequently, his cell mate woke up and found him unresponsive and raised the alarm. Prison officers and healthcare staff attended and attempted to resuscitate Craig before paramedics took over. Craig was pronounced dead at 10.34pm.

The inquest heard evidence that, after Craig’s death, three potential points of self-harm were found in his cell and that prison staff had reported to the paramedics that a particular point on the window had been there for several days. A note was also found in his cell in which he said that other prisoners were calling him names and threatening to kill him.

Craig's sister, Lisa Gibbs, is represented by Benjamin Burrows, partner and human rights solicitor at law firm Leigh Day, and Lorna Skinner KC, barrister at Matrix Chambers.

Lisa said:

“Craig was so much more than the circumstances of his death. He was a much-loved brother, son and member of our family. We have had to live for nearly four years without him while trying to understand what happened to him and whether his death could have been prevented.  

“Craig repeatedly cried out for help, but despite this, we feel the system failed him when he was at his most vulnerable. We hope that the evidence heard during this inquest will lead to meaningful change at HMP Exeter and elsewhere, so that other vulnerable people in prison are not left without the care and protection they need.”

Benjamin Burrows said:

“Craig was a vulnerable man with complex needs and a significant history of self-harm and suicidal thoughts. The evidence heard during this inquest has highlighted serious concerns about how his escalating risk was identified, recorded and responded to.

“What is particularly concerning is that many of the issues identified in Craig’s case had been identified previously at HMP Exeter.

“Lisa has shown enormous courage in seeking answers about what happened to her brother. She hopes that the conclusions reached by the jury will lead to meaningful changes and that lessons will finally be learned from Craig’s death.”