The jury at the inquest into the death of a 42-year-old Hampshire man at HMP Winchester has today concluded that prison staff failed to provide adequate support to him before he died and that prison staff were “more likely than not” informed that he had prepared a noose to kill himself but failed to act on this information.
The jury also highlighted poor communication between prison staff and healthcare staff and between prison staff and management, as well as a “…continuum of sub-optimal observations that did not meet explicit policy requirements.”
The Senior Coroner for Central Hampshire, Mr G A Short has said that he will be writing to the Ministry of Justice about concerns he has about a risk of future deaths in relation to officers’ understanding of Assessment, Care in Custody and Teamwork (ACCT) procedures including how adequate observations should be conducted and about the recording of information in relation to previous ACCTs on the prison information database, NOMIS
Mr Haydn Burton was found hanged in his cell at HMP Winchester on 15 July 2015 and
died in hospital three days later.
At 9.30am on 14 July, a prison officer was concerned about Mr Burton following him making threats to kill himself and began ACCT procedures – used by the Prison Service to support prisoners at risk of suicide or self-harm. The purpose of an ACCT is to try to determine the level of risk of suicide or self-harm posed, the steps that should be taken to reduce this and the extent to which staff need to monitor the prisoner. As part of these procedures, a Supervising Officer should have completed an immediate action plan within the hour however, this was not done until around seven hours later.
At 6.00pm that day, Mr Burton asked to speak to a “listener” (a prisoner peer supporter trained by the Samaritans) but did not see one until four hours later. The listener gave evidence at the inquest that Mr Burton told him he had already made a noose and was going to kill himself on Friday. The listener gave evidence that he told a prison officer this information but it has not been possible to trace this officer.
Prison staff should have assessed Mr Burton and held a multi-disciplinary first ACCT case review to produce a plan of action within 24 hours of ACCT procedures beginning, but this did not happen.
At 10.00am on 15 July, Mr Burton’s cellmate went back to his cell after spending some time on the wing and found that Mr Burton had hanged himself. Officers and nurses attempted resuscitation. When paramedics arrived, they found a shallow heart rhythm and took Mr Burton to hospital. Mr Burton never recovered and died in hospital on 18 July.
The jury were asked to consider six questions relating to the prison’s adherence to the ACCT procedures and the circumstances surrounding his death. They found that:
- Prison staff missed opportunities to re-asses Haydn’s risk of suicide or self-harm within the ACCT opened at 09:30am on 14 July 2015. There was no communications with the primary healthcare team so that insight into Haydn’s mental health could be discussed with a multi-disciplinary setting. It is evident from the records within the ACCT documentation that policy timelines were not met.
- The ACCT observation carried out at 09:05am on 15 July 2015 was inadequate but lies within a continuum of sub-optimal observations that did not meet explicit policy requirements.
- Failure to carry out the mandatory ACCT assessment and first case review by 09:30 on 15 July 2015 will have compromised the chance for Haydn to be assessed within a multi-disciplinary environment and with better knowledge of his medical situation and current situation.
- It is more likely than not that prison staff were informed of Haydn’s preparations of a noose on 14 July 2015. The failure to act on this information would have had a direct impact on the opportunities to support Haydn.
- The prison’s healthcare team should have been involved in the ACCT process and any insight they had could have directly affected the course of the ACCT and, in consequence, an opportunity to support Haydn.
The jury also highlighted other factors: “Specifically poor communication between prison staff and healthcare, poor communication between prison staff and higher management, and the management of inter-prisoner debt. The latter is pertinent as it seems to be a recognised problem within the prison service but little seems to be done to manage it…
“A failure to appreciate Haydn’s mental health history was detrimental to the implementation and running of Haydn’s ACCT documentation. Equally the discrete areas within healthcare compromised the holistic view of Haydn’s needs. There was no single, overarching point of contact to manage Haydn’s overall care in prison, further exacerbated by staff turbulence and ad hoc training.
“Compliance with national policy could have changed the chain of causation and missed opportunities that culminated in Haydn’s death.”
An independent investigation into Mr Burton’s death was carried out by the Prisons and Probation Ombudsman, Nigel Newcomen. Reporting in April this year, the investigation found there were serious failings in the operation of the prison’s suicide and self-harm prevention procedures at HMP Winchester.
The Ombudsman highlighted his concerns that staff at Winchester did not operate Prison Service suicide and self-harm prevention procedures properly, and in line with national policy, to support Mr Burton and keep him safe. He went on to identify a number of the deficiencies in suicide prevention procedures in previous investigations of deaths at HMP Winchester.
Clair Hilder, a solicitor at law firm Hodge Jones & Allen represented Mr Burton’s family at the inquest, she said: “There were clear failings in relation to protecting Haydn throughout his time in HMP Winchester, particularly in the 24 hours before he was found hanging. The jury has recognised that staff at HMP Winchester repeatedly failed to follow self-harm and suicide prevention procedures specifically designed to protect those at risk.
“Every officer who has given evidence at the inquest has sought to excuse their failings as a result of them being too busy or inexperienced. As the Coroner stated, 2015 was not a good year for HMP Winchester because of the high number of deaths at the prison. Worryingly, these issues aren’t just confined to HMP Winchester. Staff shortages are leading to the Prison Service gambling with prisoners’ risk of self-harm and suicide, as is evident from the national increase in prisoners taking their own lives in custody.
“Whilst improvements appear to have been made at HMP Winchester, we still have some concerns and are pleased that the Coroner has indicated he will be making a Prevention of Future Deaths report. We hope that the new Governor at the prison takes heed of his warnings and further changes are made as a result.”
Ms Hilder has also been instructed by the family of another man found hanging at HMP Winchester the day after Mr Burton died. The inquest into this death is currently listed to start in March 2017.
Haydn Burton was a prominent member of the New Fathers 4 Justice campaign, highlighting children’s rights including secret family courts. A statement on behalf of his family said: “Haydn was first and foremost a wonderful and loving Daddy. This was taken away from him by the secret family courts. Haydn tried all channels to get access to his daughter, unfortunately he didn’t have the resources to succeed. Being separated from his daughter broke his heart. Haydn’s death has broken us as a family and we hope in time this can be put back together. He will be forever in our hearts.”
The inquest into the death of Mr Burton at Winchester Coroner’s Court lasted 11-days. Counsel was Taimour Lay of Garden Court Chambers.
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