Multiple failures contributed to Daniel Weighman’s death

A jury in the inquest into the death of Daniel Weighman has concluded that multiple failures by prison and healthcare staff contributed to his death at HMP Chelmsford. Daniel died on 6 January 2024, three days after he was found unresponsive in his cell at the prison, despite being subject to Assessment, Care in Custody and Teamwork (ACCT) processes. The Coroner will issue a Prevention of Future Deaths report to HMP Chelmsford, and to CRG, who provide healthcare at the prison.

Daniel’s family was represented by Cian Murphy instructed by Gimhani Eriyagolla and Alisha McSporran of Hodge Jones & Allen solicitors and supported by INQUEST.

Daniel, from Westcliff-On-Sea, Essex, was the third eldest of eight siblings and was a family-oriented son, father, and brother. He cared deeply for his mother and siblings and would regularly cook for them and look after his younger brothers and sisters. After leaving school, Daniel worked as a labourer and moved out of his family home in his early twenties. He regularly visited to look after and spend time with his mum.

Daniel was on remand at HMP Chelmsford at the time of his death. His healthcare records included that he had a history of psychotic symptoms such as auditory hallucinations – for which he had previously received treatment. However, between his arrival in October 2022 and his death in January 2023 he was not seen by the mental health team – despite a referral.

On 1 January 2023 he reported that he would self-harm. Neither prison officers nor a paramedic who spoke to him opened an ACCT support plan. The jury concluded that the failure to open an ACCT plan on this day contributed to Daniel’s death.

On 3 January 2023 Daniel said that he was “hearing voices” and that he needed to be seen by the mental health team. Later in the afternoon he was seen with self-harm injuries. Although an ACCT plan was opened, the jury concluded that staff did not follow best practice procedures, and that observation levels were not appropriate, both of which contributed to Daniel’s death.

Two hours later he was found unresponsive in his cell and, despite optimal hospital care, he died on 6 January 2023. 

The jury delivered a narrative conclusion, highlighting several failings which contributed to his death, including but not limited to:

  • The failure of healthcare staff to assess Daniel’s risks of self-harm/suicide in light of the information contained on SystmOne.

  • Inadequate communications by healthcare staff of Daniel’s potential level of risk.

  • The lack of adequate understanding of healthcare staff and prison officers about their duties under the ACCT process.

  • A serious failure in appropriate ACCT training for healthcare and prison staff at all levels.

  • Inappropriate observation levels when an ACCT was opened on 3 January 2023.

The jury concluded that Daniel did not receive adequate support at HMP Chelmsford from prison and/or healthcare staff from 1st January 2023.

Chloe Weighman, Daniel’s sister, said: “Danny, at his core, was a kind and loving person, and while he made a few mistakes in his life, he never deserved this. HMP Chelmsford has taken Danny from us. If Danny was given the support he so desperately asked for, we would not be where we are today. He was repeatedly failed by the prison and healthcare service, who failed to carry out their basic responsibilities towards him, and we have paid the ultimate price for those failures.”