Simon McBride died on 21 March 2014 at HMP Liverpool after he was found hanging in his cell. The inquest jury identified numerous failed opportunities to refer Simon for a mental health assessment and care which would have prevented his death.
Mental health assessments of Simon from the previous three years in other institutions indicated a high risk of self-harm and suicide. The inquest jury found that HMP Liverpool failed to address these appropriately upon arrival at the prison.
Continuity of care, communication between healthcare and discipline staff and inadequate staffing levels were also criticised by the jury.
“Due to several missed opportunities to refer him for help, inefficient communications between public services and inadequate policies, Mr McBride did not receive the support he needed. When Mr McBride was transferred on an open ACCT (Assessment, Care in Custody & Teamwork) it is more likely than not that there was a failing to review his medical notes in more depth, during his first few days at HMP Liverpool."