Following a 3 week inquest at Preston Coroner’s Court the jury have returned the rare and serious conclusion that “there were several significant factors that contributed to the death of AJ. These factors combined to a gross failure by neglect that led to [the death]…his death could have been prevented at this time”
The deceased died in HMP Garth as a result of death by hanging. Due to incidents of violent bullying, he had been placed on a specialist wing (‘the RSU’) 12 months prior to his death. He was monitored under the ACCT system. Two days prior to his death, he missed his morning medication and was deselected from his wing and moved back to the main wing. He was placed in his cell as a segregated “Rule 53” prisoner without any attempt to follow the correct procedures, including a mental health assessment.
He was left in his cell for 34 hours without access to a shower, vital medication (including quetiapine, an anti-psychotic and tramadol) and any distraction materials.
The jury returned a conclusion of suicide with a narrative of gross neglect which stated:
- There were several significant factors that contributed to the death of AJ. “These factors combined attributed to a gross failure by neglect that lead to AJ’s death and if these factors were addressed his death could have been prevented.”
- The Senior Officer on the RSU wing who completed the ACCT post-closure on the day AJ was transferred missed an opportunity to re-evaluate the risks.
- There was a failure to refer AJ to a Population Management Meeting for a multi-disciplinary discussion for de-selection. This was a significant factor contributing to his death. This omission meant that there was a failure to open an ACCT document when transferred. This would have afforded him the protection of a risk assessment.
- Prior to AJ’s transfer, there was no risk assessment taken by either the transferring wing or the receiving wing. This was a “gross failure” by the custody manager, who left the transfer down to a senior officer who was unfamiliar with the wing and its processes.
- There was no reason to keep AJ segregated, “prolonged confinement in his cell was detrimental to his mental health and contributed to his death”. No safety algorithm was completed.
- Healthcare had not noticed that AJ had missed three separate medications over a 48 hour period. This medication was vital to AJ’s wellbeing.
The matter has been referred to the Home Office as a result of the findings.