Ryan was an inmate at HMP Lewes and had been transferred to the healthcare wing following a serious self harm attempt just two days prior to the fatal incident in which he ligatured with a belt.
On the evening of 22 April 2017, he was found with a ligature tied around his neck. The ligature was seen to be tied around the top of his cell door, having been tied through the cell door hatch which had been left open by healthcare staff. Ryan sadly died in hospital on 26 April 2017.
Ryan had a working diagnosis of Emotionally Unstable Personality Disorder which meant that he would often experience a heightened reaction to situations and would ruminate about his issues. During his seven weeks in custody at HMP Lewes, Ryan ligatured on five occasions as well as committing further attempts of self harm.
Ryan’s risk of self harm
One of the key issues which the inquest explored was Ryan’s state of mind at the time of his death. Prior to his move to the healthcare wing, Ryan was on M wing, where he had suffered an assault by another inmate and subsequently self harmed. Evidence was heard by the prison that if Ryan was concerned about threats from other inmates then his risk profile would change. There is evidence that on 22 April an officer had spoken to Ryan about moving back to M wing following discharge from healthcare.
An inquest was opened into Ryan’s death and was heard over the course of five days commencing on 13th May 2019 in front of HM Assistant Coroner for East Sussex, Mr Healey-Pratt.
After hearing all the evidence at the inquest, the jury found that whilst Ryan deliberately chose to attach a ligature to himself, he did not intend to take his own life.
At the time of his death, Ryan was subject to the ACCT procedure, which is designed to monitor inmates who are at risk of self harm and/or suicide. As part of the ACCT process he was placed under regular observations and would have case reviews to discuss his progress, which were meant to be multi-disciplinary. The ACCT process also involves creating and updating a Care Map of the issues which the inmate is dealing with and how to address these.
Evidence was heard by a number of discipline and healthcare staff responsible for Ryan’s care. The inquest revealed that;
Following the serious suicide attempt on 20th July, Ryan’s Care Map was not updated and self harm triggers were not updated. Ryan’s level of risk was considered to be low and his levels of observations were reduced;
These changes were made by a prison officer who had very little knowledge of Ryan and had no previous dealings with him before this review which hampered decision making in the assessment of risk;
The ACCT process involves each inmate being allocated a case manager. At the time, the case manager defaulted to whoever was on duty at the time of review, which led to the reviews having no consistency.
The jury concluded that he was at a high risk of self harm and this had a direct and causal connection with his death. They concluded that on the evidence presented there were failures by HMP Lewes to respond to an obvious risk of self harm due to an inadequate staffing level on the healthcare wing and that this had a clear and direct connection with his death. They were of the opinion that there were no failures by medical staff at HMP Lewes.
The jury also found that the following matters caused or contributed to Ryan’s death:-
- Lack of phone calls,
- HMP Lewes’ resourcing on the healthcare wing,
- The complex nature of EUPD which Ryan suffered,
- Inadequate ACCT reviews,
Emergency response and treatment
There was a delay in staff entering Ryan’s cell when he was found. Healthcare staff did not enter Ryan’s cell until prison officers were present. The decision whether or not to enter a cell is risk assessed by staff. The issue that arose in this case was that there were no prison officers situated on the wing during the night. This decision had been as a result of understaffing at HMP Lewes at the time of Ryan’s death.
It was admitted by nursing staff that attended Ryan’s cell that they that did not administer the oxygen cylinder during Ryan’s resuscitation attempt. Evidence was heard by a lead resuscitation officer that the consequences of providing oxygen would be that some of the oxygen loss caused by the placement of the ligature could have been reverted which would have hopefully improved the outcome.
The jury found that there was a delay in providing medical oxygen, but were unable to determine if this contributed to Ryan’s death.
At HMP Lewes, first aid training is conducted yearly for medical staff, however, for prison staff, one prison officer said that he hadn’t had any first aid training for approximately 16 years, despite it being part of his job description that officers have a duty of care to prisoners and are often the first responders in emergency situations.
Ligature points in the healthcare wing
Ryan ligatured by creating a loop with bedding by using gaps in the cell door frame and the open cell door hatch. These doors were highlighted as a concern prior to Ryan’s death in Sussex Partnership NHS Trust’s annual audits, as potential ligature points. Despite this, no action was taken to rectify this and the doors remain unchanged.
It was agreed that healthcare staff ought to have been aware of inmates using the doors as a potential ligature point. Evidence came to light during the inquest that the cell door hatches were supposed to be closed; however, they were always kept open. As a direct result of Ryan’s death, the hatches are now kept closed.
Preventing future deaths
During April 2017, HMP Lewes was placed under ‘Special Measures’ due to the prison being considered as not functioning to the required standard and not meeting targets set. HM Prison and Probation Service can give a prison special measures status when it has been assessed to need additional specialist support to improve to an acceptable level. A more recent report by HM Prison and Probation Service has stated that the prison has had a worsening performance since being placed in special measures, which was described as ‘deeply troubling’. According the HM Chief Inspector of Prisons, the findings at HMP Lewes were “indicative of systemic failure within the prison service.”
As a result of Ryan’s death, and having heard evidence that raised sufficient concern that further deaths may occur in the future if action is not taken, the Coroner is considering whether to issue a Prevention of Future Deaths report as a result of this death. A decision will be made shortly.
The family of Ryan Trimmer were represented by myself (Kelly Darlington of Farleys) and Ifeanyi Odogwu of Garden Court Chambers. If you require legal advice relating to the inquest of a family member, please contact Farleys’ inquest team on 0845 287 0939 or email us through our online contact form.
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