Jury identified systematic failures in relation to suicide and self harm management in a G4S run prison

Friday 27 October 2017

On Friday 20th October 2017, the jury at the inquest into the death of Jagjeet Samra returned a critical narrative conclusion identifying crucial failures by G4S prison authorities and staff.

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36-year-old Jagjeet was found hanging in his cell on 26 May 2016 in HMP Parc – a prison run by G4S.

Jagjeet was subject to suicide and self-harm management  in the prison and was required to be observed every half an hour.  This was conducted by a live CCTV camera which was displayed in the Safer Custody Unit (SCU) office.  On the night of 25th May 2016, Jagjeet was able to take his own life by using a ligature point in a blind spot within his cell which was not visible on the CCTV camera.

The officer on duty that night had recorded in the observation record that Jagjeet was completing a jigsaw puzzle at the three observations from 10.30pm onwards.  In fact, the CCTV subsequently showed that Jagjeet was not visible at all on the camera at any of these checks.  He was not visible on the CCTV camera for a period of over two hours, without any check of his cell being conducted.

When the officer finally did decide to conduct a check, which was prompted by hearing a bang, it took approximately thirty minutes for another officer to join him in order for them to enter the cell. On entry, Jagjeet was found hanging.

The jury found that his observations were ‘inadequate’ and ‘conducted contrary to policy’ and that it was inappropriate that assistance was not requested sooner. Since Jagjeet’s death the Prison Officer who was responsible for the observations has been dismissed.

Strikingly, the jury also identified systemic failures in the overseeing of the suicide and self-harm management system by the G4S prison allowed for the individual failure to make adequate observations of Jagjeet. A senior member of management from the G4S prison accepted that there was no system of “spot checking” officers observations to monitor that individuals were conducting their observations correctly.

Following representations made by the family, the Coroner agreed to write to the Ministry of Justice and G4S to raise concerns regarding staffing levels and cell design.

Selen Cavcav, senior caseworker from INQUEST said:

“The jury’s conclusion in Jagjeet’s inquest, once again brings scrutiny to private companies who continue to fail to provide basic care for  prisoners who are in crisis. We hope that the systemic failures which have been identified by the jury do not gather dust and that proper action is taken on the ground to prevent future deaths.”

INQUEST has been working with Jagjeet Samra's family since July 2016. The family is represented by Catherine Oborne of Garden Court Chambers and Matt Foot of Birnberg Peirce & Partners.

Catherine Oborne is a member of the Garden Court Chambers Inquests and Inquiries Team.

This press release was originally published by INQUEST.

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