Inquest Finds HMP Wormwood Scrubs Inmate Died Following Failings By Prison And Mental Health Services

The conclusion comes after psychiatric expert witness Dr Dinesh Maganty described the decision to refuse necessary medication as “not one that a reasonable body of psychiatrists would logically support”

An inquest has today concluded that Wayne Hurren died from suicide after suffering a mental health relapse which followed failings in his treatment. The jury also found that failings by prison staff may have contributed to his death.

Wayne Hurren was found dead in his cell at Wormwood Scrubs on March 16, 2019. Wayne, aged 58, was found unconscious in his cell at HMP Wormwood Scrubs on March 16 2019, with a deep wound in his throat which had been self-inflicted by Wayne using a ‘broken toilet seat’.

The inquest was held at West London Coroner’s Court before HM Acting Coroner for West London, Lydia Brown and a Jury, between June 20 and July 11 2022. Over the course of the inquest, 22 witnesses gave evidence.

Wayne had diagnosis of Schizoaffective Disorder and was serving an 8-year prison sentence at the time of his death. The inquest heard Wayne’s death came after a relapse in his mental illness which followed a decision by prison psychiatrists to stop and later to refuse to reinstate his antipsychotic medication despite a request by him.

Wayne had a long-lasting history of mental health disorders; he was under mental health care within the community prior to his imprisonment in 2017. Wayne was prescribed antipsychotic moderate depot injection for over 20 years prior to his death in 2019 and had a history of becoming ‘erratic’ and ‘unpredictable’ when not being compliant with his antipsychotic medication. These periods sometimes ended in incidences of self-harm.

During his criminal prosecution, two different psychiatrists instructed by Wayne’s legal representatives diagnosed him as displaying active psychotic symptoms and deemed him unfit for trial. They recommended that Wayne be admitted to a psychiatric unit for treatment. In light of Wayne’s apprehensions towards claims made about his mental state, he proceeded to sack his criminal solicitor in November 2017. Wayne’s family have said this act was ‘a product of his active mental illness’. Wayne went on to plead guilty in April 2018 and was sentenced to 8 years and 4 months imprisonment. Despite the opinions and recommendations of those psychiatrists, Wayne was never assessed by an outside psychiatric unit.

Whilst in prison, Wayne spent a large amount of his time in segregation (a unit of prison normally used for punishment), claiming it made him feel “most comfortable” and “best looked after”.

Wayne’s condition began to deteriorate when his prescribed depot injections were stopped by a prison psychiatrist on August 7, 2018. This was done with the understanding that a review would take place regarding whether Wayne required alternative antipsychotic medications – a review that never took place, leaving him without a prescription of antipsychotic medication for the first time in decades. It was also revealed that Wayne was expressing ‘paranoid beliefs’ and was set to be reviewed. This review never took place, on the basis that there was ‘no clinical indication’.

After Wayne was refused his antipsychotic medication, he repeatedly expressed that he was in pain and that his body was “crying out” for depot injections. In the weeks leading up to his death, Wayne experienced various digestive and urinary system illnesses. It was also recorded that he was struggling to sleep, and that he felt ‘nobody cared’ about how he was.

An independent consultant psychiatrist, Dr Dinesh Maganty acting as the court’s expert witness, told the inquest that:

• the evidence suggested Wayne was suffering from a relapse of his schizo-affective disorder, resulting in ‘impulsive behaviour’ which increased his risk of self-harm;
• the decision of the prison mental health team to refuse to prescribe Wayne his antipsychotic medication was ‘extremely brave’ and a decision ‘not one that a reasonable body of psychiatrists would logically support’;
• the withdrawal of antipsychotic medication in persons with severe and enduring mental illness should be done gradually and under close supervision, ideally in a hospital setting; and
• the physical symptoms Wayne was suffering from in the period leading up to his death had likely been amplified in his mind to the point that he was preoccupied by them – which ‘catastrophising’, along with low mood and impulsive behaviour, is typical of a relapse in schizoaffective disorder.

On the afternoon of March 15, 2019, according to the prisoner in the next cell, Wayne began to give away his personal belongings to other prisoners including cigarettes and food. That evening, Wayne rang his emergency bell seven times between 13:09 and 16:19 to no answer. When he rang his bell again at 16:22, an officer attended, and noted that Wayne had barricaded his cell with furniture. That night Wayne refused his dinner at 16:48 and had further checks until 20:00 with no concerns raised. The same prisoner heard Wayne smashing furniture in his cell at around 22:00.

The night duty officer who oversaw the residential night wing log, claimed to have completed his mandatory wing roll check at 21:10 and signed the roll check to that effect, however CCTV footage showed he did not. The same night officer failed to complete a further mandatory check on any of the cells on the wing at 05:10 the following morning. He was later made subject to disciplinary proceedings in relation to these failings, but resigned before they could be completed. In his evidence to the inquest, the night officer claimed that he had not carried out the checks as he had been feeling unwell; and that he had informed a senior prison officer of the fact that he was not well enough to carry out the second check. The inquest heard no evidence in support of this claim.

At 08:50 on March 16, 2019, Wayne was discovered dead in his cell by a prison officer conducting a morning roll check. It took 10 minutes for staff to access Wayne’s cell due to the cell having been barricaded and staff being unable to find the anti-barricade key. They required the assistance of a workman who happened to be in the prison at the time to open the door using an electric drill. Upon entering, Wayne was found unconscious on the floor with a deep throat wounds caused by a broken toilet seat. Despite Wayne showing rigor mortis, resuscitation was attempted. Paramedics arrived, and he was pronounced dead at 09:05.

The inquest concluded that Wayne died of suicide whilst suffering from a relapse in his mental ill health. The jury delivered a highly critical narrative conclusion, stating:

“Wayne’s relapse in combination with the failure to recognise and understand the symptoms of relapse by the mental health team probably contributed to his death.

Overall, there were failings in the treatment and management of Wayne’s mental health which, in combination, possibly contributed to Wayne’s death. These included inadequate holistic care specifically communication and reviews between the mental health and physical health team, and the refusal to prescribe anti psychotic medication on Wayne’s request. Furthermore, insufficient direct senior reviews and monitoring of Wayne’s mental health between Wayne and his treating consultant psychiatrist.

There were failings within the prison service which included the failure to consider and open an ACCT on the 6th February 2019 as recorded in the Mercury Intelligence system. Alongside this there was the failure to carry out both the evening and morning roll call cell check on 15th and 16th March 2019. It is possible these could have influenced events.”

Cormac McDonough, partner at Hodge Jones & Allen, representing the Hurren family, said: “As was apparent from the evidence heard at the inquest, Wayne was suffering from serious and enduring mental illness that required careful and considered psychiatric treatment. His condition was managed reasonably well outside of prison; however, from the time of his arrival at HMP Wormwood Scrubs, there was a significant deterioration in the quality of psychiatric care provided to him. The decisions to suddenly stop and to refuse to reinstate Wayne’s antipsychotic medication are quite bewildering given what was known about his mental health history, and they appear to have been a major factor in his mental health relapse and ultimately his death. Like every prisoner, Wayne deserved to receive medical care at least equivalent to what would be provided in the community. It is clear from the inquest’s findings that this did not happen. I hope that this inquest conclusion will compel the psychiatric care providers within the prison to urgently review their practices to ensure that similar tragedies are avoided in future.”

Wayne’s daughter, Connie Hurren, said: “My brother and I were never left with any doubt over how much our Dad loved us. He was such an affectionate man and never got tired of telling us how much we meant to him. I wish more than anything he was still here with us. We are devastated by his death and as a family we remain angry and upset that he did not get the care he so clearly needed while he was in prison. However we are grateful to the jury for their conclusions; it feels like justice for my Dad. I hope that some good will come out of this inquest, and that the staff concerned and others in the prison service learn lessons from Dad’s death so that no other family is put through this ordeal.”

Wayne’s family were represented throughout the inquest by Cormac McDonough, partner at Hodge Jones & Allen and legal counsel Tom Stoate of Doughty Street Chambers.