Damages have been paid to the son of a prisoner who was found dead in his cell after prison staff missed 18 scheduled observations despite knowing he was a ‘self-harm risk’.
Our client was found dead in his cell having taken his own life. However, at an inquest the Coroner concluded that a failure of the prison to adequately review his safeguarding arrangements may have contributed to his death.
The man had a history of depression and self-harm before he was in prison and had experienced a ‘low mood and anxiety’ behind bars.
Vicky Richardson, Head of Civil Liberties at Hudgell Solicitors, represented his son in a legal case following his death and says there were clear failures to keep him safe given his fragile mental state.
“Our client’s father was under an Assessment, Care in Custody and Teamwork (ACCT) review, which exists to identify and help prisoners at risk of self-harm and suicide,” she said.
“The fact he was on this review demonstrates that it was known and understood in this prison that he posed a real and immediate risk to himself.
“In the days before his death, he reported that he was receiving threats from other inmates and he was worried that others wrongly believed him to be a sex offender.
“A Challenge, Support and Intervention Plan (CSIP) referral began into the threats he was facing, which according to the prison’s own policy ought to have been completed within 72 hours. However, this had not even started at the time of the prisoner’s death, nine days later.
“A couple of days before he took his own life he self-harmed, causing superficial cuts to his wrists and forehead. A review was then carried out at which he spoke about being ‘dead by tomorrow’, so his fragile mental state was very clear.
“He was then meant to be checked at two hourly intervals, but over the next two days, CCTV footage showed that 18 required observations were not carried out.
“These observations were missed yet still recorded as being carried out, with five different prison officers having apparently signed those false entries.”
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Inquest led to Coroner issuing Report to Prevent Future Deaths to HM Inspector of Prisons
Following the inquest into the prisoner’s death, the Coroner issued a Report to Prevent Future Deaths, writing to the prison’s governor and HM Inspector of Prisons, warning that the failings identified could lead to further deaths if repeated.
Hudgell Solicitors pursued legal action on behalf of his teenage son, with whom he had a ‘close and loving relationship’.
As part of the case it was alleged the prison had breached its duty of care by failing to carry out observations, leaving him able to take his own life.
The Ministry of Defence offered a five-figure damages settlement, without making any admissions, which was accepted.
“There is of course no cause for celebration for our client in this case as we acted on behalf of a teenage boy who has had to come to terms with the fact that he will never see his father again,” said Mrs Richardson.
“We can’t ever turn back the clock but importantly in this case the clear failings of the prison staff were highlighted, investigated and shared with others.
“There were obvious, reasonable preventative measures that could and should have been taken to protect this man and had those steps been there is a real prospect or substantial chance he would not have taken his own life.
“He was let down by an inadequate system, poor training and a lack of supervision and oversight in respect of his self-harm risk management. We hope important lessons have been learnt
“Another worrying aspect to this case was that 18 observations were missed yet recorded as being carried out, with five different prison officers having apparently signed those false entries.
“Those officers demonstrated an awareness of the necessity of these observations by falsifying the records, and we trust that this matter has been appropriately addressed at this particular prison in the hope that this can never happen again.”
