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Inquest Farleys Solicitors LLP

Kieran Gray – Death at HMP Preston

Farleys were instructed to represent the family of Mr Kieron Gray of Blackburn in connection with the inquest into his death and in connection with a civil claim for damages arising out of his death.

On 26th August 2013 Kieron Gray was found collapsed on the floor of the shower at HMP Preston, some 20 hours after being transferred into custody. He made four deep lacerations to his body over areas associated with major blood vessels with a disposable razor. Sadly, Kieron Gray died in hospital later that day due to a massive haemorrhage.

On 22nd June 2011 Kieron Gray was convicted of the offence of arson after setting fire to his ex-partners flat in January 2010. In 2010, he developed a spinal abscess which resulted in him losing the use of his legs. With the support of his immediate family, and intensive physiotherapy Kieron Gray hoped to be able to walk again in the future. In early July 2011, Kieron Gray was evaluated for a pre-sentence report by an experienced Probation officer from Lancashire Probation Trust who concluded in the self harm section of her report and conclusion that;

If he received an immediate custodial sentence, I would consider him to be at very high risk of suicide and this information would need to be conveyed to the appropriate people from the point of sentence.

A psychiatric report was further commissioned by his criminal solicitors which highlighted the significant risk of suicide posed by Kieron Gray if he were to receive a custodial sentence.

Kieron Gray was sentenced to 2 years imprisonment and transferred to HMP Preston which removed the protective factors in his life such as the support of his family and rehabilitation at the Rakehead Clinic.

Inquest

The family, Ministry of Justice, Lancashire Probation Trust, Lancashire NHS Lancashire Foundation Trust and G4S Care and Justice Services UK Limited, were all recognised as Interested Parties.

The inquest considered a number of issues surrounding Kieron Gray’s high risk of suicide and how this information was communicated from Probation through to discipline staff at HMP Preston.

Although the judge, Kieron Gray’s barrister and his solicitor had been aware of the immediate risk of self harm that would materialise upon Kieron Gray being given a custodial sentence, no warning was passed to the Court Custody Staff.

Both of the reports were placed in a sealed brown envelope and given to the Court Custody Staff. They were not read at any point during the transfer of Kieron Gray to prison.

It transpired within the evidence that once these reports arrive in prison they are unread in the majority of cases by both discipline and healthcare staff. The evidence of the Probation Trust was that it was their belief that this information becomes available immediately via the shared information system, OASys however, this information is released to the prison overnight.

Lancashire Probation Service delayed in faxing the ROSH warning of a “very high risk of suicide/self harm” and was unable to offer any explanation for this. When the fax was sent, it was faxed to Reception and to Healthcare. The officer who found the fax left it on the nurse’s desk and failed to make any attempts to locate Mr Gray or alert staff to the warning.

The second fax sent to Healthcare was collected by a nurse and taken to the healthcare wing where Kieron Gray was located. It remains unclear what happened to the fax at that point but it was lost by Healthcare staff until the following morning, by which time Kieron Gray was in the shower with a disposable razor.

These failures in communication meant that the prison was in possession of the warning of immediate risk of suicide/self harm for a full 20 hours and none of the staff were aware of it or indeed that Kieron Gray would shortly take his own life.

Verdict

The Jury found that Kieron Gray had of a massive haemorrhage and found that:

…On the 26th August 2011 at HMP Preston, Mr Kieron Patrick Gray, by means of a razor, cut himself four times to his neck and groin whilst showering. His injuries later caused his death by massive haemorrhage at Royal Preston Hospital.

The jury concluded that Kieron Gray took his own life.

Of note in this case, there was no evidence for a jury to make any determination of the outcome of any informed assessment of Kieron Gray’s suicidal ideation and intent. Consequently, the Coroner was unable to leave any additional questions to the jury other than short for verdicts.

Rule 43

The Coroner issued a detailed Rule 43 report and has written to probation and prison services across England and Wales to highlight the failings which he believed were not limited to HMP Preston.

The Coroner recommended that relevant authorities in England and Wales undertake an urgent review as to whether or not each probation trust in England and Wales;

• Notifies Prison Escort and Custody Service in detail either prior to or at point of sentence of an offender’s risk of self harm and is aware that the PSR may not be read for weeks after the receiving prison accepts the offender;
• Is of the erroneous view that OASys is immediately available to the receiving prison and that each probation trust makes alternative arrangements to convey time sensitive information to the receiving prison;
• Is acting in accordance with PSI 74/2011 Early days in custody – Reception staff in, First night in Custody and Induction to custody;
• Has immediate access to information contained in OASys and when this information considered;
• Has considered whether or not psychiatric reports should be available to Healthcare and the rationale for not making such information available;
• Has a robust system in place for the receipt of ROSH forms and for ensuring that in any appropriate case ACCT systems are fully engaged;
• Finally, it is recommended that a review of the relative safety of various disposable razors issued to prisoners who are the subject of an ACCT is undertaken.

Civil Claim

A claim pursuant to the Human Rights Act 1998 was brought on behalf of Mr Gray’s two daughters, father and brother. They were entitled to seek compensation for grief, distress and anguish on account of Mr Gray’s death. Each Claimant had a close and supportive relationship with Mr Gray and as such they clearly satisfied this “victim status”.

A Human Rights claim was also brought on behalf of Mr Gray. The Ministry of Justice and NHS Foundation Trust accepted full responsibility for Mr Gray’s death and damages were awarded to each Claimant in the sum of £8,500.00. Damages were also awarded to the estate of Mr Gray in the sum of £2,000.00 to reflect pain and suffering.

To arrange a free initial consultation with a specialist inquest solicitor call Farleys on 0333 331 4602 or submit an enquiry online.

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