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An inmate at the scandal-hit prison which accidentally set a sex offender free was able to kill himself when staff failed to notice that he was a known suicide risk. Steven Davidson took his own life at HMP Chelmsford in March last year while he was behind bars awaiting a sentencing hearing. An inquest heard Mr Davidson had harmed himself several times during a previous spell in prison in 2012 and 2013, including multiple incidents of using a ligature. But details of his past history of self-harm were not passed on to prison staff in 2024 when he managed to take his own life, a jury found. HMP Chelmsford was at the centre of a national scandal this weekend after convicted sex offender Hadush Kebatu was accidentally set free from the jail. Kebatu, a migrant who came to the UK illegally on a small boat, was supposed to be transferred to an immigration detention centre when his prison term – for sexually assaulting a 14-year-old girl in Epping – came to an end. But prison staff let him go instead, even though Kebatu reportedly made efforts to re-enter the jail. He was eventually picked up by the Met Police on Sunday, but the incident has sparked a major review of prison security and release procedures. The inquest into Mr Davidson’s death concluded on October 22, with the jury finding that he had managed to make a ligature which was used to end his life. In a report calling for action to avoid future similar death, Coroner Stephen Simblet set out that Mr Davidson “had been in prison on a previous occasion, in 2012-13, during which he had self- harmed on a number of occasions, including ligaturing himself to the point of unconsciousness on more than one occasion”. He said information on the incidents was held on a system for healthcare records which staff at HMP Chelmsford could access. “However, the evidence from all of the healthcare witnesses involved, which included a number of Registered Mental Nurses carrying out a mental health review of the deceased’s care, and the Nurse conducting the initial Reception Health Screen, was that none of those people were aware of the deceased’s history. “Evidence was given that such past history is clinically significant to any assessment of the risk of self-harm. “The evidence from some of these staff was that they had not been able to navigate the records very easily, and/or despite interrogating the records, had not found this important information.” He added that senior figures from HCRG Care Group, which provides healthcare services to the jail, told the inquest that the medical records can be manually searched, for terms such as “self harm” or “suicide”. The Coroner raised concerns about the ability of staff at the prison to navigate the medical records, and urged that they are better trained to be able to search the records of a new prisoner for warning signs of self-harm and risk. The coroner’s court has been sent to the private healthcare contractor, as well as to the Ministry of Justice. Justice Secretary David Lammy revealed that Kebatu’s accidental release from HMP Chelmsford was due to “human error”. He has launched an independent review of prison release systems in the wake of the embarrassing incident.
