Family call for lessons to be learned after inquest into teenager’s death at young offenders’ institute finds series of failings

Wednesday 29 March 2017

The family of a teenager who was found hanged at a young offenders’ institute, despite telling staff that he wanted to die, has called for lessons to be learned from his death. Tom Stoate represented the family of Ondrej Suha, who was 19 when he died. Tom was instructed by Gus Silverman of Irwin Mitchell and supported by INQUEST.

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Ondrej was remanded to HMYOI Brinsford on 12 September 2015 while awaiting trial for burglary and assault. He had sold property from his mother’s house while she was on holiday and slapped her on the wrist during an argument.

On 30 November, he tied ligatures around his neck and pulled them tight on two occasions. He tried to prevent staff from removing the ligatures and told them that he wanted to die. Ondrej was placed on a suicide prevention and self-harm regime. However, this was cancelled the following day by a prison officer who later said that he didn’t know that Ondrej had tied two separate ligatures.

On 7 December, Ondrej pleaded guilty and was given a 14-month custodial sentence. Ten days later, Ondrej’s cellmate tried to hang himself while Ondrej was in the room.

Shortly before being locked in his cell for the night on 21 December, Ondrej, who had lived in the UK since he was four years old, was served with Home Office papers advising him that he was liable to be deported following his sentence. The prison officer who served Ondrej with the papers told the hearing that he would have preferred to do this during the core prison day.

That night officers could not get a response from Ondrej, who had partially covered the window in the cell door with toilet paper. There was a delay of several minutes before officers opened the door and found Ondrej hanged.

The inquest heard evidence that no one tried to resuscitate Ondrej until a nurse arrived seven minutes later and the control room officer did not call an ambulance until the nurse requested it. The inquest heard that this was in breach of national prison service guidance which states that an ambulance must be called immediately once a prison officer identifies that a prisoner’s life is at risk.

Paramedics arrived and took Ondrej to New Cross hospital in Wolverhampton where he died on Christmas Day with his mother and sister at his bedside.

Inquest findings

A six-day long inquest concluded in Stafford on 28 March 2017, with the jury:

  • Finding that Ondrej’s death was caused by being told that he could be deported just before being locked away for the night and therefore outside of the ‘core day’
  • Finding that the prison had breached Ministry of Justice guidance that an ambulance should be called immediately once a prison officer identifies that a prisoner’s life is at risk
  • Expressing concerns over the lack of training for prison officers
  • Expressing concerns over failures to communicate and coordinate clearly within the prison service in order to ensure continuity of care for Ondrej

The Senior Coroner for South Staffordshire, Andrew Haigh, added that he would be sending a Regulation 28 Prevention of Future Deaths report to the head of the National Offender Management Service setting out his concern that inadequate training for night staff and a national policy allowing prisons to operate with only one CPR-trained member of staff on duty at any one time could lead to future deaths.

This followed an investigation into Ondrej’s death by the Prison and Probation Ombudsman, which concluded that the suicide and self-harm prevention regime in Ondrej’s case was “poorly managed and did little to support him”; that the decision to close the suicide and self-harm prevention regime on 1 December 2015 “underestimated Mr Suha’s risk so soon after his self-harm” and breached the requirement for such decisions to be taken following input from a multidisciplinary team; and that the emergency response was “very poor” and involved concerning delays.

Ondrej’s sister Andrea Suhova said:

Our family has been devastated by losing Ondrej. Knowing that more could have been done to protect him has only made our pain worse. Ondrej grew up in the UK and thought of himself as British through and through. We will never understand why the prison thought it was appropriate to give him that letter, knowing full well it was informing him he might be deported, before locking him away for the night. He had only recently tried to harm himself and told staff that he wanted to die. 

It is now so important that the prison service, and HMYOI Brinsford in particular, learns from Ondrej’s death so that other young people are safe and other families don’t have to experience the same pain as us.

Gus Silverman of Irwin Mitchell, representing Ondrej’s family, said:

“The failures in this case are depressingly familiar from other prison deaths. Whether because of poor training, understaffing or simple lack of care, HMYOI Brinsford failed to keep Ondrej safe.  

This inquest has also heard worrying evidence that the prison service considers it is appropriate to allow prisons to operate with only one member of CPR-trained staff on duty at any one time. Ondrej’s family now look to the head of the National Offender Management Service to act on the concerns of the Coroner regarding this policy.”

Deborah Coles of INQUEST said:

“Our society needs to ask itself how many more prisoners must die before prison safety is made a priority. 

It defies belief that such unsettling news was delivered before night lock-up to someone with a history of self-harm and who’d told staff he wanted to die. This was cruel and insensitive treatment of a vulnerable teenager who should have been supported and protected. 

Familiar criticisms in the way prison staff manage prisoners at risk and the emergency response points to the lamentable failure of [the National Offender Management Service] to act on these systemic national issues of concern that are repeated time and again at inquests.”

The jury’s conclusions followed an investigation by the Prison and Probation Ombudsman, which concluded that the suicide and self-harm prevention regime in Ondrej’s case was “poorly managed and did little to support him”; that the decision to close the suicide and self-harm prevention regime on 1 December 2015 “underestimated Mr Suha’s risk so soon after his self-harm” and breached the requirement for such decisions to be taken following input from a multidisciplinary team; and that the emergency response was “very poor” and involved concerning delays.

The case has been covered by the Guardian.

Tom Stoate is a civil liberties specialist and a member of Garden Court’s Inquest and Inquiries Team.

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