Winchester prison: 'Computer shortcomings' warning over inmate's death

Andy Goldstraw was found hanged in his cell at HMP Winchester in 2018

An "inadequate" and "misleading" prison computer system may have led to the death of an inmate, a coroner has said.

Andy Goldstraw, 43, from Poole, Dorset, was founded hanged at HMP Winchester in November 2018.

Prison staff were "seemingly unaware" of his previous suicide attempts outlined in a 240-page digital health record, coroner Simon Burge said.

In a Prevention of Future Deaths Report, he said the unwieldy system could put other inmates at risk.

'Wholly inadequate'

Mr Burge, an assistant coroner in Hampshire, said the "technical shortcomings" of the software - SystmOne - were a matter of "considerable concern".

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

"A busy, under-pressure mental health nurse or doctor is very likely to struggle to find the relevant entries... which may explain why... too much reliance was placed on how [Mr Goldstraw] presented during interview."

He said a key part of the software was "wholly inadequate" and contained information about the inmate that was four years out of date.

As a result, he said, Mr Goldstraw was not judged to be a suicide risk.

'High risk'

Another report by the Prisons and Probation Ombudsman said a nurse had allowed the inmate to keep medicines in his cell even though he had attempted an overdose six months earlier.

"The computerised assessment showed Mr Goldstraw as high risk for holding his medication," it said.

Central and North West London NHS Foundation Trust, which provided the jail's healthcare, said: "We accept the notice from the coroner; we will respond... with the necessary action plan."

The Prison Service said it would remind staff about the importance of risk assessments.