In the Cheshire Coroner’s Court

Before HM Assistant Coroner Ms Charlotte Keighley

Monday 7 October – Tuesday 15 October 2024

The inquest into the death of Jason Lee McQuoid concluded on 15 October 2024. Assistant Coroner Charlotte Keighley, sitting with a jury at Cheshire Coroner’s Court in Warrington, heard the inquest over 7 days, with the jury highlighting several failures with Jason’s care.

Jason died by suicide in his cell at HMP Risley on 2 March 2021. He was 37 years old.

In January 2021, Jason arrived at HMP Risley. As part of his reception screening, he requested mental health intervention. The jury found that a failure to refer Jason for mental health intervention at this point possibly contributed to his death. The jury heard evidence that if this had been done, he would have been considered by the mental health team within a week.

A few weeks later, Jason’s mental health deteriorated. Over the space of five days, he displayed paranoid and ‘bizarre’ behaviour, set a fire in his cell, was restrained and segregated in the Care and Separation Unit, and was monitored under suicide and self-harm prevention procedures known as ACCT (Assessment, Care in Custody and Teamwork). There were multiple missed opportunities to consider Jason’s risk. Jason’s treatment plan was to be discussed at a dual diagnosis meeting scheduled for 26 February, but the meeting was moved to 3 March, the day after Jason’s death.

The ACCT process is designed to support someone in prison who is at risk of self-harm or suicide. The jury found that the ACCT process was used as a method of gaining trained mental health input, as the mental health referral system was over-subscribed and may not have been commenced in this case.

The mental health practitioner at the initial ACCT review did not know Jason’s history, did not consider his records and was not aware of his recent presentation. The initial ACCT was closed within hours of being opened.

The next day, the ACCT was re-opened, when Jason set a fire in his cell. Jason also said, more than once, that he was going to kill himself. He made a further request to see the mental health team.

The jury recorded inadequate communication between prison officers and the mental health team. Because of the use of agency staff, who did not have access to the prison NOMIS records, Jason’s comments about suicide were not recorded electronically. The jury found that this information was not included in the notes of the second ACCT review. The jury recorded: “This inadequate communication continued through a number of opportunities…”.

The jury also found that due to a lack of communication between reception, prison officers and the mental health team, Jason’s mental state was not fully assessed. Further, the frequency of the weekly assessment meetings did not allow for the mental health team to pick up on the rapid deterioration of Jason’s mental state.

During the ACCT review on 28 February, information was not shared which may have led to different safeguards being taken by the mental health team.

The jury heard evidence that, on the night of 1-2 March, Jason was on hourly observations under the ACCT process. However, the jury concluded that “a lack of a robust handover procedure and the observations not carried out irregularly to the stated frequency on the balance of probability did contribute more than minimally to Jason’s death”.

Joyce McQuoid, Jason’s aunt, speaking on behalf of his family said:

“As a family we are devastated. Jason has left behind two much loved children who are  now are forced to face the future without their father. The impact of his death has had catastrophic consequences on the rest of the family and for three years we have been unable to grieve properly.

“Jason was left to suffer for days whilst begging for help allowing his mental health to rapidly decline. Jason hadn’t eaten or slept in three days. He was dismissed, ignored and his most basic human rights left unattended . How can this be permitted to happen in the 21st century .

“We can only hope that lessons have been learned within the structure of the prison system to prevent future unnecessary deaths.

“Jason was loved by many and has left a huge void in our lives.”

Alice Wood of Farleys Solicitors said:

The jury’s findings show how Jason wasn’t able to access mental health care despite multiple requests to see a mental health practitioner. Further, the ACCT process is extremely important in a prison setting to ensure the safety of individuals at risk and it is worrying that the officer carrying out the ACCT on the night of Jason’s death did not seem to grasp the importance of these processes. We are grateful to the Coroner and the jury for their consideration of these matters.

Jodie Anderson, Senior Caseworker at INQUEST, said:

“Yet again we see the toxic combination of a dehumanising prison environment, a lack of professional care or curiosity and zero effort to look at the underlying causes of Jason’s behaviour and distress. Jason’s ‘bizarre’ behaviour was wrongly dismissed as being due to a mistaken perceived drug use, an excuse which meant that staff took no proactive steps to ensure Jason received the care he needed.
 
“Failures in processes will continue to lead to deaths but of equal concern is the apparent ease with which a person’s dignity, care and access to support simply evaporates when they enter those four walls of HMP.
 
“Just a month before his remand, Jason witnessed his friend being murdered. Imagine what society would look like if we prioritised addressing the root causes of mental ill health over punishment.”

The Interested Persons were:

  • Jason’s family

  • Ministry of Justice

  • Greater Manchester Mental Health NHS Foundation Trust

Jason’s family were represented by Alice Wood and David Corrigan of Farleys Solicitors and Cian Murphy of Doughty Street Chambers.

Jason’s family were also supported by Jodie Anderson, Senior Caseworker at INQUEST.