A coroner has issued a report urging both Manx Care and the Department of Home Affairs (DHA) to make improvements to the prison system after the deaths of two prisoners.

Coroner Graeme Cook oversaw the jury inquests into the deaths of Jurby Prison inmates Craig Anderson and Christopher Corkill which were held this year. Both men took their own lives in their cells by suffocating themselves.

Mr Anderson, 28, died on November 25, 2022 while Mr Corkill, 46, was found dead in his cell on February 24, 2023. There was also a further death when Kaan Douglas was found dead in his cell in March 2020.

A damning Prison Ombudsman report on Isle of Man Prison was published following the death of Mr Corkill who had a history of self-harm.

In his report published last month, Prison Ombudsman Adrian Usher found mental health services within the prison were ‘inadequate, unsafe, and not equivalent to what is available in the wider community’.

His investigation followed a separate inspection from His Majesty’s Inspectorate of Prisons (HMIP) which took place between February and March last year which found many ‘missed opportunities and poor systems of accountability’.

A follow-up review was conducted, between April 30 and May 2 this year, where the inspectors found ‘encouraging’ improvements.

Both the Department of Home Affairs (DHA) and Manx Care have addressed many of the issues since the deaths with the DHA revealing 70% of the improvements cited in this report and the one by the HMIP have been introduced.

But this latest report by the coroner has thrust the spotlight once more on the island’s prison system and welfare of inmates.

In his report to DHA Minister Jane Poole-Wilson, Mr Cook says: ‘I said at the conclusions of both inquest that I would consider making a report to yourself as the Minister in charge of an authority that has power to take action to prevent future similar deaths, and this I now do.

‘I also make this report to the Chief Executive Officer of Manx Care (Teresa Cope), as a further authority that I find has power to take action to prevent future similar deaths.

‘It is not the place of myself, as Coroner of Inquests, to recommend action that should be taken to prevent future similar deaths. Such decisions must be taken by the Department and/or Manx Care.’

But Mr Cook said that, ‘having had the benefit of considering all the evidence with respect to the two deaths’ there are 12 matters he believes should be considered.

These include:

* Improved access to mental health professionals and mental health provision within the prison.

* Prison healthcare to have automatic access to prisoners’ health records on initial arrival at the prison.

* Manx Care to ensure a medication review on each prisoner’s arrival.

* For there to be an input from a mental health professional into the opening and closing of the Assessment, Care in Custody (ACCT) for those who are at risk of suicide or self-harm.

*A trigger point for an ACCT to be when a prisoner is sentenced and constant cell observations should be in place for the first 48 hours.

* For there to be regular inspections carried out by the HMIP.

In the letter to the DHA Minister and Manx Care, Mr Cook said: ‘I would ask that you provide a reply to this letter within the next 56 days setting out what, if any, action you intend to take further to my report.’

In reacting to Mr Cook’s report, a DHA spokesperson said: ‘We welcome the Coroner’s recommendations and will now review and consider them alongside the ongoing actions following inspections from both His Majesty’s Inspector of Prisons and the Prisons and Probation Ombudsman.

‘Since the tragic deaths of Kaan Douglas, Craig Anderson and Christopher Corkill in custody the Department has made several changes, with Manx Care, to improve the way vulnerable people are supported in Prison.

‘Good progress has been made on those actions to date. Of note is the introduction of the new ACCT system which provides a more robust approach to supporting vulnerable prisoners. Manx Care’s improvement plan has also made a significant difference to prisoner healthcare.

‘We offer our deepest sympathy and apologies to the families of Kaan, Craig and Christopher and hope they will be allowed to grieve in peace now the formal proceedings have concluded.’

Meanwhile, Deputy chief executive and director of nursing at Manx Care Paul Moore previously said a huge amount of work has been carried out to address the issues and says that work will continue.

He said: ‘The important thing to get across is that we have developed a healthcare improvement plan for the prison which has originated from the recent deaths.’

Mr Moore also said a lot of work has gone into change the procedures within the healthcare provision at the prison.