Inquest Jury finds HMP Bullingdon failed Chegory McCarty on numerous occasions

Friday 14 October 2022

Chegory’s family are represented by Una Morris of Garden Court Chambers, instructed by Irène Nembhard, Rebecca Pelekanou and Marte Lund of Birnberg Peirce. 

The content below is reproduced with permission from a Birnberg Peirce release.

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The inquest into Chegory Paul McCarty’s tragic death concluded on Thursday 13 October 2022 at Oxford Coroner’s Court, before Senior Coroner Darren Michael Salter, sitting with a jury.

Chegory, who was born in Antigua, had been remanded into custody at HMP Bullingdon at the time of his death on 25 May 2020, when he was aged just 35 years old. He was awaiting a retrial, after a first trial had resulted in a hung jury, but was hopeful that the retrial would not proceed due to insufficient evidence and that he would soon be released back home to his loving partner and child.

Chegory, described by his family as hard-working, caring and always wanting to help others, had obtained a job in the prison as a COVID cleaner, where it was his role to keep the communal areas of the prison clean, so as to minimise the risk of infection during the early stages of the COVID-19 pandemic.

During the course of the evidence, it was confirmed that around the time of Chegory’s death, HMP Bullingdon had a significant problem with synthetic cannabinoids, which was known about by prisoners, prison officers and the governors of the prison. The problems with access to and use of illicit substances, including psychoactive substances, was also noted at an inspection of HMP Bullingdon by HM Inspectorate of Prisons in July 2019.

The jury found that the medical cause of Chegory’s death was “Ingestion of Synthetic Cannabinoid (5FMDMB-Pica)”. However, against a background of no evidence at all of Chegory’s deliberate consumption of synthetic cannabinoids and strong evidence that he did not consume such substances and was in fact deeply opposed to the consumption of them, the jury was unable to “conclude the ingestion mechanism”.

The jury found that on 24 May 2020, before Chegory died, prison officers failed to identify his intoxicated state on a number of occasions, including at the 20.55 roll check, which possibly contributed to his death. The jury recorded that Chegory died at some point between 21.29 on 24 May 2020 and 12.45 on 25 May 2020, when he was discovered life extinct. They therefore also found that, despite officers visiting the cell a number of times during the morning of 25 May 2020, “wider process failures” on the part of the prison led to Chegory not being discovered deceased for a period of at least six hours.

The jury said:
“Mr McCarty was discovered life extinct in his cell 231 at HMP Bullingdon, 1 Patrick Haugh Road, Arncott, Bicester by the Healthcare staff at 12.45 on 25 May 2020. The range of death based on evidence provided is assumed to be between 2129 hours on 24 May 2020 and 0645 hours on 25 May 2020. The medical cause of death on the balance of probability is synthetic cannabinoid (5F-MDMBPica). We cannot conclude the ingestion mechanism of the synthetic cannabinoid. Alcohol is known to have been consumed on 24 May. However, based on the consideration of evidential findings the Jury has concluded that this is not a contributing factor to Mr McCarty’s death.

The first recorded slurred speech of Mr McCarty was at 1311 on 24 May 2020, there were numerous interactions with prison officers following this time i.e., 1600 (24 May) dinner, covid duties at 1800 hours (24 May), which could have identified Mr McCarty’s intoxication and subsequent action being taken.

Failure to complete the 2055 roll check on 24 May 2020, in accordance with prison training, which included looking through the hatch, did result in the missed opportunity to identify Mr McCarty’s intoxicated state, which would have resulted in the admission to the healthcare unit. There is a possibility that this contributed to his death.

Wider process failures, on the balance of probabilities that did not contribute to his death:

  • There was no elicited response obtained during the breakfast and welfare checks, if Mr McCarty had been alive but unresponsive this could have contributed to saving his life.
  • The prison cell was opened for lunch at 1137 on 25 May, Mr McCarty’s cell mate advised the prison officer that Mr McCarty was unwell. However, the prison officer did not enquire into his wellbeing. Changes to national government guidelines on Covid directly impacted the transfer of knowledge to the prison officers on new Covid welfare procedures and processes. Leading to the prison officers not being fully conversant with their process check requirements. Internal cascade failures of new instructions enhanced the issue further as exhibited by the welfare check not being conducted during breakfast at 0802 on 25 May 2020.”

The Senior Coroner confirmed that he would make a Prevention of Future Deaths report to HMP Bullingdon surrounding an issue revealed during the course of the evidence about responses to prisoners when requests are made for a move to a drug recovery spur.

Rachael Freer, Chegory’s partner, said: “Chegory was repeatedly failed by HMP Bullingdon, both during his life and after his death. They failed to check Chegory’s safety and well-being repeatedly and we strongly believe his life could have been saved if they had done their jobs correctly. HMP Bullingdon then denied my wonderful partner and the father of my son the dignity and respect he deserved, by leaving him in the cell for hours, without even noticing that he had died, despite their duty of care towards him. I am shocked and traumatised by the lack of care for human life and HMP Bullingdon’s attempts at defending the indefensible during the course of the inquest. The systemic failures of prisons continue to put thousands of lives at risk every single day. We call upon the authorities to stop putting those lives at risk now. As a family, we would never wish anyone the heartbreak, pain and suffering we have been forced to endure for the rest of our lives.”

Irène Nembhard of Birnberg Peirce solicitors, who represents Chegory’s family, said: “After being repeatedly denied assistance by the British State, Chegory’s family in Antigua raised and borrowed money so that at least some members of the family were able to attend the inquest into his death. Chegory’s mother, Marilyn, and brother, Danny, travelled all the way from Antigua to the UK to sit in a court room in Oxford and listen to the traumatic evidence of multiple failures to respond appropriately to Chegory and to properly check on his safety and wellbeing while he was supposed to be being cared for by the same State that then denied them assistance to attend the inquest of their much loved son and brother. They are devasted by Chegory’s death and the knowledge that his life could have been saved. They wish to express their heartfelt thanks to the jury who delivered them justice for Chegory. They want Chegory to be remembered for the good and caring son, brother and father that he was.”

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