(Image: Hertfordshire Police)
A coroner has raised concerns after the death of a convicted murderer in York.
David Clairmonte, who was jailed for life for murdering a pensioner with a hammer in Luton in 2012, died aged 39 in York Hospital on October 4, 2024.
A report following his death said Clairmonte had been transferred to HMP Full Sutton, near York, in October 2023 after spending nearly six years at Stockton Hall Psychiatric Hospital.
Coroner Edward Steele said Clairmonte had a complex personality disorder and a history of self-harming.
He said Clairmonte was taken to York Hospital on September 27, 2024, following “repeated episodes of self-harm” and died on October 4, 2024, after refusing treatment.
In a narrative conclusion, the coroner said Clairmonte’s history of self-harming caused “serious degeneration” to his health and a “depletion of his physiological reserves”, leading to complexities that resulted in his death.
Clairmonte’s cause of death was given as intra-abdominal sepsis, acute haemorrhagic pancreatitis and hypokalaemia.
After the inquest, Mr Steele raised concern over a lack of availability at Stockton Hall Psychiatric Hospital to treat Clairmonte, and about delays to prison officer escorts at HMP Full Sutton.
The coroner said it was heard during the inquest that Clairmonte had been moved from Stockton Hall Psychiatric Unit to HMP Full Sutton as there was not a place to treat him in a high security setting at the hospital.
Mr Steele said evidence revealed there was a “diminishing number of placements” in high-security settings for patients “who require specialist care concerning personality disorders”.
The coroner also raised concern that prison officer escorts from HMP Full Sutton to accompany Clairmonte to hospital “were not identified quickly enough to facilitate an expeditious transfer, during a medical emergency”.
He said the inquest heard that Clairmonte was delayed in leaving prison for almost an hour after an ambulance crew attended “due to prison officer escort staff not having been identified".
“During that period, the oxygen cylinder brought in by the paramedics had run out,” the coroner said.
Mr Steele wrote to the Ministry of Justice, Department of Health and Social Care, Care Quality Commission, NHS England and the Priory Group after Clairmonte’s death, saying action must be taken to prevent future deaths.
Clairmonte was 'not deemed suitable' for hospital - NHS boss
In a letter responding to the coroner, the NHS’ national medical director, whose name was redacted, said any patient who is remitted back to prison will have been reviewed by the hospital to ensure they no longer require treatment for a mental disorder or that no effective treatment for the disorder can be given in hospital.
“In Mr Clairmonte’s case, we have been advised by our regional colleagues that the East of England Secure Services Collaborative discussed his case several times during the year,” the director said.
“Attempts were made to identify alternative medium secure personality disorder units due to his enduring mixed personality disorder.
“However, no unit accepted him. He was discussed with a high security hospital but not deemed suitable.
"The clinical leads reviewing his case advised that as he had another 20 years on his sentence and had been in the personality disorder service for over five years without substantial engagement in psychological programmes, a remission to prison was justified.
"They did highlight that enhanced observations may be the only option to maintain his safety.
“Therefore, Mr Clairmonte’s remission to prison was completed on clinical grounds, and not due to a lack of mental health beds to treat his personality disorder.”
They added: “NHS England is not aware of any shortage of placements for patients who require specialist care for personality disorders within a high-security setting.”
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A Care Quality Commission spokesperson said: “We have received the prevention of future death reports from HM Coroner and will use them in our ongoing monitoring of this service and to understand whether any regulatory action needs to be taken.”
The Priory Group, which runs Stockton Hall Psychiatric Hospital, declined to comment.
The Ministry of Justice has been approached for comment.
The Department of Health and Social Care has also been approached for comment.
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