The inquest into the death of Aaron Taylor concluded on Wednesday 29 October 2025, with the jury finding that Aaron died by suicide whilst an inmate at HMP Garth.  His death was contributed to due to multiple failures across all levels of the prison regime.

The Inquest was heard over 8 days at Preston County Hall in front of HM Senior Coroner for Lancashire and Blackburn with Darwen, Mr Christopher Long.

Background

Aaron Taylor was recalled to prison on 03 January 2023 and was initially detained at HMP Preston.  He felt his recall to custody was unjust and told staff that he intended to self-harm and would kill himself given the chance.  He had a history of self-harm.  Aaron was managed under the Prison Service suicide and self-harm monitoring procedures (known as ACCT) at this time.

On 07 February 2023, Aaron was transferred to HMP Garth after reporting being sexually assaulted by another prisoner at HMP Preston.  He was seen by the mental health nurse on arrival at the prison and a referral was made to Manchester Survivors, and it was determined that Aaron should have some further mental health support.

Throughout this time, Aaron’s mother was expressing her concerns with the prison and probation in the community and was desperately seeking help given her concerns about her son.

Throughout the 8-day hearing, evidence was put to the Jury, including evidence of live witnesses, statements of witnesses that were read to them by the Coroner, other documentary evidence including prison policies, photographs, and CCTV.

The Jury heard that:

  • When Aaron was seen on his arrival at HMP Garth in early February 2023, and was referred to Manchester Survivors and for more support around his mental health, the waiting list to see Manchester Survivors was several months’ long. In fact, Aaron never saw anyone from that service before his death.

  • Further, the Jury heard that there was no psychologist in post at the prison, so Aaron would not receive any specialist treatment for his mental health. Only lower level workbooks around wellbeing could be offered.

  • An independent investigation completed after Aaron’s death found that he should have been offered interim mental health support whilst waiting for an appointment.

  • Aaron self-harmed on 23 March 2023. An ACCT was opened but he did not have a mental health assessment.  This monitoring was closed on 10 April 2023, without the input of mental health.

  • There was a further incident of self-harm on 20 April 2023. ACCT procedures were again started.  The investigator found that a full mental health risk assessment should also have been completed at this time. It was not.  The ACCT was closed on 02 May 2023.

  • On 04 August 2023, Aaron caused deliberate harm to himself and was taken to see a nurse in the Health Care department by a Prison Officer. It was assumed by both individuals that an ACCT had been opened, but no one checked.  An ACCT was not in fact opened.

  • A further referral was made to mental health at this time, but the task was completed incorrectly on the system, without Aaron having been seen. The investigator found that Aaron would likely have received mental health support through to the date of his death, had he been seen.

  • The injury later resulted in an infection and outside hospital treatment being required. An ACCT was still not opened.

  • The Jury heard that Aaron’s allocated keyworker had not had any meaningful contact with him due to the regime at the prison at that time and staff shortages. The officer was not aware of how often such sessions should be taking place.

  • Despite Aaron being on a priority list for keywork, meaning there was a greater need for him to be seen, this was not done as it should have been.

  • A prison officer checked on Aaron through the observation panel in his cell at 5pm on 27 August 2023 and had no concerns.

  • The night prison officer checked on Aaron again at 7:30pm and again did not have any concerns.

  • A further check should have been carried out between 5am and 6am on 28 August 2023 and the internal documentation suggested it had been. However, when the CCTV was reviewed, the check did not appear to have been completed, and no evidence was put forward to suggest otherwise.

The Jury’s Findings

The Jury delivered their conclusions to the coroner on 29 October 2025.

They found that Aaron’s death was contributed to as a result of multiple failures in the measures taken to prevent self-harm and suicide, across all levels of the prison regime – including by nurses, a GP, a mental health nurse, both senior and junior prison officers, his prison offender manager and the Governor.

They went on to say that inadequate preventative steps and assessments, lack of documentation, inability to adhere to policies and procedures, and a lack of professional curiosity from prison staff and healthcare workers, who were employed by Greater Manchester Mental Health Foundation Trust at the time, all contributed to Aaron’s death.

Concerns of the Coroner

HM Senior Coroner for Lancashire and Blackburn with Darwen, Mr Christopher Long will issue a Report to Prevent Future Deaths to both the Ministry of Justice and PPG who are now responsible for the healthcare for the prison.

Whilst he did acknowledge some changes from both parties, he reminded himself of Article 2 ECHR – the right to life, and how the state has a positive obligation to protect that.

The Report to Prevent Future Deaths to PPG is to highlight his concerns that there remains no psychologist in post at HMP Garth.  Whilst this was the case at the time of Aaron’s death, it has also been the case for the last six months.

In relation to the Ministry of Justice – responsible for HMP Garth, the Coroner was not satisfied that all staff were adequately trained in relation to ACCTs and the opening of the same and checking whether the same have been opened.

Secondly, in relation to Key Working.  Whilst he acknowledged that the national system has changed, the coroner was concerned that the witness did not know how often the sessions should be taking place and said it would have been difficult for anyone to persuade me not to issue (a report to prevent future deaths) on this point. 

Aaron’s Mum, Maria, said

I was begging both probation and the prison to help Aaron.  I knew he needed additional support, but he did not get it. 

Whilst I am pleased the Jury were able to return findings reflecting on what I knew had happened, I did not bring my son into the world to be a lesson learnt. 

Aaron is talked about, remembered and missed every single day.  My heart will always be broken. 

I am grateful to the coroner for his time and attention to my son’s case.

 

Aaron’s family were represented by Kelly Darlington, Partner, and Natalie Tolley, Associate, of Farleys Solicitors and David Baines, Barrister, of St Johns Buildings.