A CORONER has raised concerns over the death of a Poole man who took his own life while in custody.

Andrew Goldstraw had been at HMP Winchester ahead of a court case at Bournemouth Crown Court in November 2018.

The case, which concerned a charge of wounding with intent, had been adjourned after the 43-year-old appeared at Poole Magistrates' Court the previous month before he was remanded into custody.

He was found dead in his cell on November 14, eight days before he was due to appear in court.

An inquest into his death took place earlier this year, with a jury reaching a conclusion that he had intended to take his own life.

In their narrative conclusion, the jury set out concerns regarding the care Mr Goldstraw received while in the prison between October 23 and November 14.

A preventing future deaths report by assistant coroner for central Hampshire Simon Burge said the jury found that an assessment, care in custody and teamwork (ACCT) plan should have been opened and the absence of such care plan "would more than minimally have helped to prevent his death".

"The ACCT would have resulted in awareness of his risk factors and would have created better cross service communication," Mr Burge's report said.

Mr Goldstraw was suffering from an adverse psychological state due to a combination of drugs (spice) and psychoactive medication (Fluoxetine and Mirtazapine) taken prior to his death, the jury found.

Raising his concerns in the report, Mr Burge said Mr Goldstraw's medical notes contained numerous references to suicidal ideation and deliberate self-harm attempts, but the mental health nurse was seemingly unaware of the relevant entries on his arrival at the prison.

Acknowledgement of this history would have opened an ACCT, the coroner said.

Mr Burge said the computer system at the prison – SystmOne – makes it "difficult" for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment.

"Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions," said the report.

"At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them."

Mr Burge said that action should be taken to prevent future deaths, with his report being sent to prison healthcare provider Central and North West London NHS Foundation Trust, the government legal department and the governor of HMP Winchester.

He added that the head of healthcare at the prison had indicated that she intended to provide a bulletin to all staff following the inquest, however Mr Burge said this does not address the technical shortcomings of the computer system, which present a matter of "considerable concern".