Jury find gross failures and neglect at HMP Garth in the Inquest of Prisoner “AJ”

Southerns Solicitors Inquest Team provided support and representation to the family of a prisoner who died in HMP Garth as a result of hanging.  After three weeks of detailed evidence the jury returned the conclusion that “There were several significant factors that that contributed to the death of AJ. These factors combined contributed to a gross failure by neglect led to AJ’s death and if these factors were addressed his death could have been prevented.”

12 months before his death AJ had been transferred to a specialist wing for vulnerable prisoners (“the RSU”) due to incidents of bullying by other prisoners. He was managed on a number of occasions under the ACCT process, which is a multidisciplinary care planning process to support prisoners identified as being at risk of suicide or self-harm.

Two days before his death AJ was late for morning medication.  He was deselected from the RSU and moved back to the main prison population. This was done without following the agreed method of discussing such transfers in the weekly ‘Population Management Meetings’.

On transfer AJ was kept in his cell as a segregated ‘Rule 53’ prisoner despite none of the correct segregation procedures being followed.  This meant that he was not afforded a mental health assessment or Governor Review that should have taken place. Evidence was heard that if these had taken place it was likely that the segregation would not have been approved.

AJ was left in his cell for 34 hours without access to exercise, phone calls, a shower, distraction materials and vital medication prescribed for his mental health and back injury.

The jury returned a conclusion of suicide with a narrative of gross neglect which stated that were several significant factors that contributed to the death of AJ. “These factors combined attributed to a gross failure by neglect that lead to AJ’s death and if these factors were addressed his death could have been prevented.” These factors included;

1. The Senior Officer on the RSU wing who wrote up the ACCT post-closure on the day AJ was transferred missed an opportunity to re-evaluate the risks. “This lack of action contributed significantly to AJ’s death.”
2. There was a failure to refer AJ to a Population Management Meeting for a multi-disciplinary discussion for de-selection. This was a significant factor contributing to his death. This omission meant that there was a failure to open an ACCT document when transferred. This would have afforded him the protection of a risk assessment.
3. Prior to AJ’s transfer, there was no risk assessment taken by the transferring wing. This was a “gross failure” by the custody manager, who left the transfer down to a senior officer who was unfamiliar with the wing and its processes.
4. There was a “seriously inadequate” handover on transfer, as a result of the lack of a risk assessment being carried out.  This failing is due to there being no written procedure in place
5. There was no adequate assessment of AJ by the Senior Officer on the receiving wing. This was poor practice and a serious contributing factor that led to AJ’s death.
6. There was no reason to keep AJ segregated in his cell. “Prolonged confinement in his cell was detrimental to his mental health and contributed to his death”. The most severe failing was the misapplication and failure to follow the protocol of Rule 53. No safety algorithm was completed.
7. Healthcare had not noticed that AJ had missed three separate medications over a 48 hour period. This medication was vital to AJ’s wellbeing.

HM Senior Coroner Dr James Adeley confirmed that he will be issuing ‘Prevention of Future Death Report’, such were his concerns in this case.

Ashleigh Howard, Solicitor at Southerns, who attended the Inquest throughout with the family said:

“AJ’s death should not have happened and I am pleased that his family finally have some answers about the circumstances surrounding his death. The Inquest provided the appropriate forum to explore how AJ came by his death and also in what circumstances.  We hope that the Prison will now put robust measures in place to ensure such failures do not happen again”

In addition to Southerns, the family wished to express thanks to INQUEST (charity) and Ms Amy Rollings of Nine St John St Chambers.