The inquest into the death of Samuel Hayden was heard on the 26th June over the course of five days at Liverpool Coroners Court by HM Area Coroner Anita Bhardwaj, assisted by a Jury.


The court heard that Sam was a 28-year-old man who’d been in prison before as a young man but had ‘turned his life around’, forming relationships, a stable home, and employment. This was abruptly ended when he was recalled to HM Prison Liverpool in July 2020 following an allegation whilst in the community.

Sam had struggled with his mental health and was under a prison multi-disciplinary care scheme know as (ACCT) for some time. Additionally, he was treated with medication to treat his anxiety and depression.

Sam continued to struggle with prison life under the Covid-19 regime and the stress and strain it was putting on his relationship. Sam’s mother, in giving evidence, explained that Sam could not be described as a quiet introverted person and the evidence that he kept himself to himself and got on with life was out of character.

The court heard Sam was not compliant with his medication, sometimes missing his daily dose. This culminated in Sam agreeing to stopping his medication on the 19th February 2021. The court heard that no reason was ever noted as to why he missed his medication or why he intended to stop it. Healthcare workers had neglected to fully complete documentation or add notes to the electronic healthcare system, SystmOne. Actions described by the head of healthcare in evidence as “poor”. It was said that this decision was reviewed by a clinician, yet no evidence of this could be found.

The court heard that Sam’s mental health continued to decline and his family would be bombarded with countless calls a day with Sam dealing with his mood swings putting further strain on his relationships. This culminated in Sam’s partner ending their relationship.

On the 11th March 2021 Sam had made 146 calls to various people, at times expressing suicidal ideation, as the family say he was in a state of crisis. The court heard how prison staff and healthcare staff were oblivious to this and Sam maintained an outward impression of being ‘a model prisoner’.

Inquest conclusions:

Sam was found hanging by ligature in his cell during a welfare check by the morning staff at approximately 7.40am on the 12th March 2021. Evidence was heard that no emergency care was appropriate owing to the amount of time Sam had been hanging. The jury found that Mr Hayden was pronounced deceased at 8.06am and died as a result of a self-applied ligature whilst alone in his cell, but it cannot be said whether he intended the act to be fatal.

The Coroner explored issues that had been raised in evidence by way of prevention of future deaths, particularly around the decision to stop Sam’s medication, the lack of assessments and what prisoners are told about this and the risks. The lack of any medical notes surrounding this was also explored. As a result of changes made in the prison following this case the Coroner was content to not write a Regulation 28 prevention of future deaths report.

Samuel Hayden’s family were represented by David Corrigan of Farleys Solicitors and Mr Sam Harmel of Kings Chambers.