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Inquest finds that prison’s failure to address bullying issues contributed to young prisoner’s death

A jury at the inquest into the death of a 21-yearold 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.

Luke Hughes was transferred to HMP and YOI Swinfen Hall from HMP Hewell, Worcestershire on 23 January 2014. During his transfer he was discovered with drugs on his person. He informed prison staff that he had been persuaded to act as a mule for the drugs by an inmate at HMP Hewell, to be delivered to inmates at HMP and YOI Swinfen Hall. The drugs were confiscated and he was made subject to disciplinary proceedings.

On 31 January, Luke tried to hang himself in his cell. Suicide and self-harm prevention measures were put in place by the prison, which included regular observations and assessment and review meetings. During the initial assessment meeting, Luke reported that he had attempted suicide because he was being bullied by the inmates who had requested that the drugs be smuggled into the prison. The inmates in question had demanded money for the seized drugs and threatened violence against Luke if he failed to pay. In response, prison staff arranged for Luke to be moved to a different wing. The prison considered this to have resolved the issue, and so the suicide and self-harm prevention measures were brought to an end. However, in a post closure meeting on 17 February 2014, Luke indicated that the bullying and threat of violence against him remained, and reported that he was scared of encountering the inmates in communal parts of the prison. No further action was taken in respect of this concern.

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. Luke was not referred for a mental health assessment at any point during the process.

Throughout February and March 2014, Luke reported ongoing threats and concern for his safety. This included threats by inmates on his wing made on behalf of those who had threatened him previously. On one such occasion, Luke caused damage to his own cell in the hope that he would be disciplined and sent to the segregation unit, where he would be safe from the bullying. In response to the numerous reports made, 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 offenders, despite Luke having provided the names of those who were bullying him. He was not considered for a mental health referral or for further suicide and self-harm prevention measures.

On 20 March 2014 Luke reported that he was scared of leaving his cell, and requested that he be transferred to a different prison. No consideration was given to this request, instead enquiries were made about a transfer back to one of the wings he had been on previously. Unfortunately, the manager of the wing in question was on leave, and so a note was made for the matter be discussed further following his return on 26 March 2014. This discussion had not taken place by the time of Luke’s death, and no steps were taken in the meantime to explore alternative ways of protecting Luke’s welfare.

On the evening of 26 March 2014, Luke was found hanging in his cell, having used his bed sheets to form a ligature. After an unsuccessful attempt to resuscitate him, Luke was pronounced dead at the scene.

Late yesterday, the jury determined that Luke died as a result of hanging and concluded following a four-day inquest at County Buildings, Stafford that the following factors had contributed to his 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 indicated 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, to consider where imprisonments can be made.

Luke’s mother and aunt were represented at the inquest by Cormac McDonough of leading civil liberties firm Hodge Jones & Allen and Ifeanyi Odogwu of Garden Court Chambers. Cormac McDonough says: “This is yet another tragic and avoidable case involving the death of a vulnerable prisoner. Luke was known to the prison to have had a history of self-harm which was linked to threats of violence and bullying; and it was obvious to all that his safety was at risk. He was clearly very scared, but despite asking prison and healthcare staff for help on multiple occasions, no steps were taken to address the route cause of the bullying. Instead on each occasion staff took the easy and short-term option of transferring him to a different wing, which never solved the problem, but merely passed responsibility to staff in a different prison wing.

“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.”

The inquest concluded on the same day the Ministry of Justice released figures showing the number of self-harm incidents, assaults on inmates and deaths in prison all rose sharply last year. There were a total of 257 prisoner deaths compared with 153 in 2006. Part of the rise is due to a steady increase in both suicides and killings behind bars; 89 of the deaths in 2015 were self-inflicted.

Over the same period there were 30,706 reported incidents of self-harm, up 24% on the previous year. Luke’s family, who do not want to be named, said: “Luke was a fantastic young man who was loved dearly by his friends and family. He had a warm and friendly personality and a smile that would brighten up a room. Although he was not a saint, he had a heart of gold, and would go out of his way to help his family and friends in whatever way he could. He was our loveable rogue. He had his own problems which led to him being in prison, but he accepted what he had done wrong, and was making plans to turn his life around when he got out of jail. He had so much to look forward to in life, he just needed to get himself on the right path, and we believe he would have achieved it if he had come back home to us. He was an amazing young man with a lot to live for, and we are devastated at losing him, but he will live on in our hearts forever.”


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Notes for Editors

The Civil Liberties team at Hodge Jones & Allen is one of the UK’s foremost teams in bringing actions against the police and state authorities for deaths in custody. The firm’s solicitors work closely with INQUEST, which works for truth, justice and accountability for families, and campaigns for policy change at the highest level.
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