Paul Thompson, who had been held on remand at HMP Norwich since March 2024, died by suicide after being struck by a freight train, an inquest concluded.

The 53-year-old took his own life on railway tracks near Elmswell Railway Station, in Suffolk, on July 15 2024.

Following the tragedy, an inquest was held at Suffolk Coroner’s Court into the death and resulted in the coroner issuing a Prevention of Future Deaths report.

Suffolk Coroner's Court, Ipswich (Image: Newsquest)

In the document, area coroner Darren Stewart detailed serious shortcomings in communication and discharge procedures surrounding the release of Mr Thompson.

Mr Stewart placed a particular emphasis on failures in the prison’s handling of his release, noting he had expressed suicidal thoughts while in custody and was under the care of prison mental health services.

Mental health concerns during custody

Mr Thompson, who had a history of functional neurological disorder, anxiety, depression and alcohol dependency, had openly discussed suicidal thoughts while in prison.

Because of these concerns, he was placed on an Assessment, Care in Custody and Teamwork (ACCT) plan. This is a formal safeguarding process used to monitor prisoners at risk of self-harm or suicide.

The coroner noted that although Mr Thompson’s mental health had stabilised to some extent during his time in custody, he remained vulnerable and continued receiving support up to the point of his release.

Suffolk Coroner's Court, Ipswich (Image: Newsquest)

On July 11, 2024, Mr Thompson appeared before Suffolk Magistrates’ Court and was sentenced to 12 weeks in prison — equivalent to the time he had already served. He was therefore ordered to be released immediately.

However, his release happened late in the evening, after normal working hours.

The report states Mr Thompson became distressed when he realised he would not immediately have access to personal belongings such as his mobile phone and bank cards, which were locked in the prison safe. He expressed suicidal thoughts to prison staff at that time.

Although staff reassured him and returned his bank cards, and he appeared calmer when leaving the prison at about 7.20pm, he was not seen by mental health staff before his release — despite being under their care.

Breakdown in communication

The coroner found that prison mental health staff were not even aware Mr Thompson had been released until the following day, when the information emerged during a routine staff briefing.

A referral was then made to mental health services in Durham, where Mr Thompson lived, but attempts to contact him failed.

Meanwhile, probation services were also unaware of his release. When Mr Thompson attended the Durham Probation Office on July 12, staff had no prior knowledge of him or his situation.

During that visit, he appeared anxious and emotional and admitted having suicidal thoughts, although he said he had no immediate plans to act on them. He was offered crisis support but declined to engage.

On July 15, he travelled by train from Durham to Suffolk, where he was later seen by the ticket machine at 5.15pm.

The station’s CCTV then shows him at 5.39pm moving from the platform towards the railway tracks.

Police later found a note at his home addressed to his family expressing his final thoughts.

A post mortem confirmed he died from multiple injuries. No drugs or alcohol were found in his system.

Coroner warns of risk to other prisoners

In his report, Mr Stewart said there were “inadequate arrangements” at HMP Norwich for releasing prisoners receiving mental health care outside normal working hours.

He highlighted failures in ensuring proper mental health discharge procedures and informing probation services promptly.

Serious concerns raised over release of prisoners after man dies by suicide (Image: Coroner's Society)

He said: “I am concerned [about] shortcomings in the internal passage of information at HMP Norwich concerning the release of prisoners in receipt of mental health care and treatment, particularly those who have expressed recent suicidal ideation.

“In addition, I am concerned as to the adequacy of information passage to the Probation Service relating to the release of prisoners from custody.

“In another case these failures may give rise to a risk of death.”

However, the coroner clarified that these failures did not directly cause Mr Thompson’s death.

The report has been sent to the minister of state for prisons, who must respond within 56 days outlining what action will be taken to prevent similar incidents.

A copy has also been sent to the Prison and Probation Ombudsman, the governor of HMP Norwich and the Norfolk and Suffolk NHS Foundation Trust.

© Eastern Daily Press