The Article 2 Inquest into the death of Lee James was heard at Stourport Coroners Court before Senior Coroner David Reid, sitting with a jury for 8 days.
Lee James was a prisoner who, since 2008, spent time at HMP Belmarsh, Frankland, Full Sutton, and HMP Long Lartin, under a life sentence.
On 15th January 2020, Lee James was transferred back to Long Lartin following accumulated visits to see his sick mother at HMP Belmarsh.
Due concerns regarding Lee’s mental health an Assessment, Care in Custody and Teamwork (ACCT) review was held. This is part of the care planning process for prisoners identified as being a risk of suicide or self harm.
Lee was supported under ACCT procedures until 22nd January and was subject to ACCT monitoring a further four times between June and December 2020. On each occasion Lee told prison staff he was concerned regarding his mother’s health and was frustrated about his accumulated visits and a possible transfer to facilitate these.
On 14th December, Lee made threats towards a member of staff and was subsequently restrained and moved to the segregation unit. Prison staff started ACCT monitoring Lee after he said he was going to kill himself. Staff were to check on him every hour.
On the morning of 16th December, an officer completed an ACCT check on Lee, recording that he was asleep, noting movement. At 07:45am the officer completed a further observation check noting Lee was in bed.
At 08:30am, another officer made an entry on Lee’s ACCT document reporting that he had checked Lee and had noted movement. The officer later admitted that he had not checked Lee this time as he should have done and had falsified the record. The officer has since resigned from their position at HMP Long Lartin.
At 09:05am, an officer went to Lee’s cell to give him his medication. He found Lee suspended by a ligature around his neck. At 09:07, the officer called a medical emergency code blue. Staff attended and began CPR. Nursing staff attended and noted signs that Lee had been dead for some time.
Jury’s findings:
The jury’s findings in relation to the circumstances of Lee’s death can be summarised as follows:
“On the morning of 16th December 2020 Lee James died at HMP Long Lartin having been discovered suspended by a ligature attached to a window in his cell.
It is admitted that the first ACCT case review on 14th December 2020 was chaired by a prison officer who was not suitably trained to perform that role. It cannot be concluded that this failing possibly caused or contributed to Lee James’ death on 16th December 2020.
It is admitted that no ACCT observation check was carried out on Lee James between 0745hrs and 0905hrs on 16th December 2020, and that a false entry was made in the ACCT ‘on-going record’ at 0830hrs which made it appear as though an ACCT observation check had been carried out at that time. It cannot be concluded that this failing possibly caused or contributed to Lee James’ death on 16th December 2020”.
With the above in mind, the jury concluded that;
“Lee James died as a result of suspending himself by a ligature from the window of his prison cell. It is not possible to determine what his intention was at the time he did this”.
The jury noted that it was “admitted that no ACCT observation check was carried out on Lee James between 0745hrs and 0905hrs on 16 December 2020, and that a false entry was made in the ACCT ‘on-going record’ at 0830hrs which made it appear as though an ACCT observation check had been carried out at that time. It cannot be concluded that this failing possibly caused or contributed to Lee James’ death on 16 December 2020.‘
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