In a damning verdict returned late on Thursday 13 June, the jury in the inquest into the death of Andrew Hall on 27 March 2009 found that he took his own life whilst the balance of his mind was disturbed, contributed to by neglect.
This is the third short form neglect verdict returned following a self inflicted death at Holme House prison.
Following three full weeks of evidence, the lengthy jury verdict listed 21 separate failures of Andrew Hall's care and treatment at HMP Holme House. These included failures in risk assessment and risk management, and serious failures in communication.
Andrew served part of his sentence at HMP Kirklevington. Whilst there, he had attempted suicide by cutting both wrists. Following a period of hospitalisation he was transferred to Holme House prison on an open ACCT (Assessment, Care in Custody, and Teamwork - the system used for prisoners who are at risk of self harm). The jury concluded that this ACCT should not have been closed. Following the (improper) closure of the ACCT, on 23 March, Andrew was further assessed by a psychiatrist who considered him to be clearly psychotic and at significant risk of self harm. Despite this, no ACCT was re-opened, a clear failure identified by the jury. The jury found that none of the nurses in the subsequent four days had read the psychiatrist's documented assessment. As a consequence, he was not afforded the level of observations, interaction and care necessary.
As a result, despite being in a camera cell, he was not being properly observed when he first inflicted a wound to his neck four days later. The jury concluded that the failure to observe and interact contributed to his death. In a devastating criticism, the jury also found 'there was an opportunity for the staff to intervene between the time when he inflicted a wound to the vein in his neck and the time when he inflicted a wound to the artery in his neck'. This period lasted around 20 minutes, during which blood could be seen on CCTV on the floor of the cell.
The full verdict is available from INQUEST.
At the conclusion of the inquest, the deputy coroner indicated that he would be reviewing recommendations made following previous inquests into deaths at HMP Holme House before drafting his own, with specific reference to continuing failures of record keeping and communications between discipline staff, nursing staff and the mental health in-reach team.
Paula Davidson, Andrew's partner said:
"The verdict today has proven Andrew's death was unnecessary and if individuals had carried out their roles there would not have been failings in his care which resulted in Andrew's death.
"There have been a number of deaths before and after Andrew's death and we hope that lessons have been learned from today's verdict which the jury have returned.
"I would not have the truth for the family and also for our little girl today if it had not been for the support from INQUEST and I would like to thank them and Fiona Borrill and Imogen Hamblin from Lester Morrill solicitors and Sean Horstead from Garden Court Chambers for all their support throughout this four year ordeal."
Deborah Coles, co-director of INQUEST said:
"Had greater care been taken been taken of Andrew this tragic and disturbing death might not have happened at all.
"The fact that this is the third neglect verdict since 2004 should be a wake up call to the prison service. Moreover, that there have been five further self inflicted deaths there since Andrew Hall died in March 2009 suggests that little has been done to address the issues raised at this and previous inquests.
"It is crucial for the safety of all prisoners at Holme House that these failings are addressed as a matter of urgency."
The inquest has been widely reported in the media, including by The Guardian.
The family is represented by INQUEST Lawyers Group members Fiona Borrill and Imogen Hamblin from Lester Morrill solicitors and barrister Sean Horstead of Garden Court Chambers. The same team represented the families of the two other self-inflicted deaths where neglect verdicts were returned at inquest.