Inquest jury finds multiple prison failures to address bullying contributed to young prisoner’s death

Monday 1 February 2016

A jury at the inquest into the death of a 21-year old Bromsgrove man who died whilst in custody at HMP and YOI Swinfen Hall in Staffordshire, has found that a number of failings by prison and healthcare staff contributed to his death.

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Ifeanyi Odogwu of Garden Court Chambers’ Inquests Team represented the family of the deceased during the inquest.

On 23 January 2014, Luke was discovered in possession of drugs during his transfer to HMP and YOI Swinfen Hall. He informed prison staff that he had been persuaded to act as a mule for the drugs by another inmate. On 31 January, Luke was discovered trying to hang himself in his cell. He reported that he had attempted suicide because inmates had demanded money for the seized drugs and threatened violence against him if he failed to pay. Suicide and self-harm prevention measures were put in place by the prison, however, they were brought to an end after just one week.

Luke informed the prison on multiple occasions in February and March 2014 that the bullying and threat of violence against him remained, and reported that he was scared. Prison staff moved Luke to a different wing a total of six times. No attempts were made to investigate the threats against Luke or to discipline the perpetrators, despite Luke having provided the names of those who were bullying him.

Luke was not considered for further suicide and self-harm prevention measures, neither was he referred for a mental health assessment at any point during the process despite stating that he wanted emotional support and was depressed. Contrary to prison service guidelines, there was no input from mental health professionals at the suicide and self-harm prevention assessment meeting, and minimal input in the process that followed.

On the evening of 26 March 2014, Luke was found hanging in his cell, having used his bed sheets to form a ligature.

Following a four-day inquest in Stafford, the jury determined that following factors had contributed to Luke’s death:

  1. Discipline and Healthcare staff failed to act on all the information available to them in managing Luke’s suicide and self-harm risk.
    2. The prison missed opportunities for Luke to have a mental health assessment.
    3. The prison failed to tackle the bullying issues.

Following the jury’s conclusion, HM Coroner for Staffordshire South, Mr Andrew A Haigh confirmed that he would be issuing a Prevention of Future Deaths Report, providing a formal recommendation to YOI Swinfen Hall to review their suicide and self-harm prevention process.

Luke’s family was represented at the inquest by Ifeanyi Odogwu of Garden Court Chambers. Ifeanyi was instructed by Cormac McDonough from Hodge Jones & Allen. In a press release, Mr McDonough stated:

“This is not only a failing on the part of individual staff members at YOI Swinfen Hall, but on the part of the Prison Service for failing to provide adequate systems, policies, training and monitoring to address the problem of bullying in prisons and to care for those affected by bullying.”


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