A recent inquest into the death of Mr Kieron Gray from Preston highlighted a catalogue of errors in his transfer from court into custody despite being a ‘very high risk’ of suicide. Farleys’ inquest solicitors represented the family of Mr Gray, who sadly took his own life within just 20 hours of being imprisoned at HMP Preston.
Following the inquest into Kieron’s tragic death, which was reported on BBC news and in the Lancashire Evening Telegraph, the Coroner made a number of recommendations. Dr Adeley, Coroner for North Lancashire and Preston, intends to write to the Ministry of Justice and Prison and Probation Service in England and Wales calling for an urgent review of procedures in place in the processing of key information when an offender is transferred from Court to Custody.
Kieron was convicted of the offence of Arson in June 2011. Prior to his criminal trial he developed a spinal abscess which resulted in him losing the use of his legs. He was receiving extensive physiotherapy in the hope that he would one day be able to walk again.
A psychiatric report commissioned by Kieron’s criminal solicitor concluded that a custodial sentence would remove the ‘protective factors’ in Kieron’s life; such as the support of his family and his physiotherapy.
Prior to being sentenced, Kieron was evaluated by an experienced Probation officer from Lancashire Probation Trust who deemed him to be a ‘very high suicide risk’ if he were to receive an immediate custodial sentence. She went on to add that this information would need to be conveyed to the appropriate people from the point of sentence.
This did not happen; and as such, no warning was given to the Court Custody staff. The Probation Trust delayed faxing the information across to the prison and when it arrived only the front page of the document was found on a desk at reception. The officer picking up the document failed to locate Kieron or notify staff responsible for him. A second fax was sent to Healthcare and was collected by a nurse. It is unclear what happened with the fax at that point but it was lost by Healthcare staff until the following morning, by which time Kieron was in the shower with a disposable razor. Kieron made four deep lacerations to his body and subsequently died.
A jury concluded that Kieron took his own life however Dr Adeley made a number of welcomed recommendations highlighting the failings which he believed were not limited to HMP Preston. Alarmingly, evidence was heard from discipline staff at HMP Preston that in most cases they do not read pre-sentence reports when offenders first come into custody. It was clear from the inquest evidence that the mechanisms by which information was communicated to court custody staff and the prison was flawed as a result of internal failures by discipline and healthcare staff.
The Coroner has also made a recommendation that an urgent review of the use of disposable razors in prison is also undertaken.
The inquest highlights the importance of a thorough investigation into the death of a loved one who has died whilst in the custody of the State. Here at Farleys we have a department specialising in Article 2 Inquests as a result of a death in prison or police custody. For many families the inquest process can be extremely overwhelming and emotionally challenging and in almost all cases, legal representation is vital.
The costs of an inquest can be significant but we are will always do our upmost to try and assist you in securing specialised representation at a forthcoming inquest. There are various funding options available, which we are happy to discuss with you during a free initial consultation. Please do not hesitate to contact our inquest solicitors for more information.
By Kelly Darlington, Inquest Lawyer, Manchester
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