Mr P sadly died at HMP Highdown on 27 May 2018.
The inquest into his death was held over 8 days and concluded on 19 March 2020.
Mr P had a history of mental health problems, substance misuse, self-harm and attempted suicide. His mental health had deteriorated in the weeks prior to his death and a psychiatrist referred him for assessment for transfer to a secure mental health unit, which did not take place prior to his death.
Mr P was sadly found hanging in his cell. The medical cause of death ascertained by the jury was 1a Ligature Suspension.
The Prison and Probation Ombudsman investigated the death and raised concerns in relation to wellbeing checks and delays in entering the cell once Mr P was found hanging.
At the inquest, evidence was heard from a number of prison and healthcare witnesses who were involved in his care at HMP Highdown.
It came out during the inquest proceedings that a healthcare nurse had completed paperwork incorrectly and observation checks were not completed at the times stated in documentation. CCTV showed the nurse carrying out an observation check and she accepted in evidence that it was likely that the ligature was there when she first attended the cell and she did not see it.
Once it was discovered that Mr P had ligatured, there was a delay in opening his cell. The nurse at the cell did not have a key to the cell and the officer did not want to open the door without another officer present. There was also a delay in a code blue being called until the second officer arrived. When the paramedics arrived, a pulse was found prior to Mr P attending hospital, where he sadly died.
The jury recorded the following conclusion:
“Mr P died on the 27th May 2018 in St George’s Hospital, Tooting. Mr P suffered from mental illness and a learning disability which made it difficult to assess his intent.
Mr P’s cell was not in an appropriately safe cell.
The level of disruption contributed to the staff’s behaviour and Mr P’s state of mind.
Inadequate information about the reasons underlying the observation regime for Mr P was passed to the night shift staff on the evening handover on 25th May 2018.
The observation regime Mr P was subject to on 25th/26th May 2018 was not adhered to fully.
Mr P did a deliberate act which caused his death although his intention is unclear.”