The daughter of an Oxfordshire prisoner found hanged in his cell says lessons must be learned after successfully pursuing a civil case against the Ministry of Justice (MOJ).
Sarah-Jane Gray took legal action after learning how staff at HMP Bullingdon, in Bicester, became ‘complacent’ with regards to her father David’s repeated threats to take his own life.
Mr Gray had a history of severe traumatic brain injury and mental illness, serious self-harm and attempted suicide, including attempted suicide by ligature. He took his own life by hanging and was found dead in a cell in the prison’s healthcare unit on March 17th, 2019.
An officer was supposed to complete a check on him at 10pm but had failed to do so. A nurse later went to Mr Gray’s cell to complete a routine welfare check and found him hanged.
At inquest a Coroner said there had been ‘errors and omissions’ in the provision of Mr Gray’s care in the days prior to his death, during which time he had made multiple verbal threats to take his own life. He had also written three notes threatening to take his own life.
Despite this prison staff and prison healthcare staff did nothing, with the inquest highlighting a failure to hand over adequate details between shifts or escalate concerns about his worrying behaviour. A Prison and Probation Ombudsman (PPO) Independent Investigation also expressed concerns about the lack of a ‘comprehensive care plan’ to manage Mr Gray’s complex mental health needs.
It said senior staff should have been asked to consider opening an Assessment, Care in Custody and Teamwork (ACCT) plan for him, which are specifically for prisoners identified as being at risk of suicide or self-harm.
Daughter took legal action to ensure lessons are learned
As a result of his death, Mr Gray’s daughter launched a civil claim against the MOJ, alleging breaches of his human rights, resulting in a five-figure compensation settlement being agreed out of court.
A mental health recovery support worker herself, she said she felt the Prison Service needed to be ‘challenged on all fronts’ to ensure lessons are learned, and that prisoners are afforded greater protection when they are a known risk to themselves.
“Being in the work that I do, in which I support people with mental health issues, I had to challenge what had happened to my father and make sure it was investigated at every level,” she said. “The reality is he was massively failed by prison officers and the prison healthcare staff and I wanted everybody who failed him to be accountable in some way and to improve for the future.
“I work with many young people who have struggles with their mental health and the professionals who come into contact with them have a duty of care to ensure they are kept safe. It can’t ever be accepted that people become dismissive of those threatening to harm themselves.
“Young people can find themselves in prison for many reasons and can become suicidal, so the systems and networks of support need to be right to help them come through and have a second chance. There needs to be systems and processes which are followed with compassion and care, and that wasn’t the case for my dad.”
Independent investigation highlighted failings and recommended change
The PPO Independent Investigation concluded there appeared to have been ‘an unofficial belief among some nursing and prison staff that Mr Gray’s threats of self-harm were simply normal behaviour for him and did not need to be taken seriously.’
It added that at the time of his death, it was the fifth self-inflicted death investigated at Bullingdon since 2016 in which staff were found to have poorly assessed prisoners’ risk of suicide and self-harm.
Vicky Richardson, Head of Civil Liberties at Hudgell Solicitors, led the claim against the MOJ and said: “Prisoners are of course held in detention as a punishment for crimes committed but the state has a duty to provide them with the same standards of healthcare and treatment as anyone outside of prison.
“That is what every family would rightly expect to happen for a loved one in prison, but there were clearly a series of failures with regards to Mr Gray.
“Due to his condition, he was a prisoner who should have been considered a serious risk of suicide and therefore should have had a specialist plan to care for him. This did not happen, and the Ministry of Justice admitted this was a failing.
“Then, despite Mr Gray telling various prison staff on a number of occasions in a matter of days that he intended to kill himself, and having written three notes which he passed to staff which said the same, the matter was not escalated and he was still not put under a special care plan.
“It appeared that at the time a large percentage of prison officers were inexperienced and that may have contributed to the concern over Mr Gray’s mental state not being appropriately communicated or escalated, and a plan not being put in place.”
In conclusion to its investigation the PPO recommended a string of required improvements, including for prison and healthcare staff to open an ACCT whenever a prisoner has recently self-harmed or expressed suicidal intent, and for prisoners with complex health or wellbeing needs to have comprehensive care plans evaluated and updated regularly.
The Ombudsman requested that it be updated on further actions taken in light of Mr Gray’s death to raise standards.
Ms Gray, who was also aggrieved that her father’s ashes were scattered without consulting the family, added: “The only positive to come from this has hopefully been that lessons have been learned and improvements have been made to how prisoners with complex mental health issues are treated and cared for, particularly at this prison but hopefully for all.
“My dad was ignored and he was badly let down. It can’t be allowed to happen again.”
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