The jury at the inquest into the death of a 27-year-old man from Hayling Island in Hampshire at HMP Winchester has concluded that the prison’s failure to instigate appropriate self-harm support measures contributed to his death, citing widespread insufficient and inadequate training and a lack of accountability in the training of agency staff.
The jury said that staff’s failure to open an Assessment, Care in Custody and Teamwork (ACCT) document – a procedure used across the Prison Service to assist in understanding the triggers for suicide or self-harm and help provide support – contributed to the death of Sean Plumstead.
Father of two, Sean, was found hanging in his cell by his cell mate during the evening of 15 September 2016. The cell’s emergency bell cell had been pressed at 18.39 and staff took over 10 minutes to respond; the prison admitted it was a failing that this had not been answered within the required five minutes. Sean was transferred to hospital and subsequently died on 18 September, less than a month before he was due to be released.
The jury found that prison staff’s failure to attend Sean’s cell within five minutes of the bell being pressed possibly contributed to his death. They commented that the emergency cell bell system was not fit for purpose.
Sean, who was described by prison staff as a model prisoner, worked in the prison’s Clothing Exchange Store under the supervision of two staff members. Approximately, two days prior to his hanging, Sean had asked one of the staff members what the best way to commit suicide was, but the staff member failed to record or report this, passing it off as ‘banter’. He also described Sean as having been unusually distracted at work and making mistakes on 15 September which was unlike him.
The inquest heard that neither of the staff members supervising Sean’s work were prison officers, they were provided by the private facilities management company, Carillon. Neither staff member had received ACCT training. One of these members of staff explained when giving evidence that, as of October 2017, he had still not attended an ACCT training course. The other staff member, who received the training just two months ago, said that he would have started ACCT procedures for Sean had he been trained, which would have triggered support being provided to Sean.
Prior to the inquest, the Senior Coroner for Central Hampshire, Grahame Short took the unusual step of issuing the prison with a Prevention of Future Deaths Report (PFD) ordering the governor to address concerns about documentation following Sean’s death not being properly preserved.
At the conclusion of the inquest yesterday, the coroner indicated that he would now be writing a further Prevention of Future Deaths report to both the Ministry of Justice and Carillion.
Sean’s death, and the issues it highlights at HMP Winchester, are not isolated. During its July 2016 inspection, the Chief Inspector of Prisons noted that HMP Winchester had failed to implement its 2014 recommendation that emergency cell bells should be answered promptly. Further, HMP Winchester had already received a series of PFD reports ordering them to address concerns about the mandatory ACCT training and the speed of its delivery to staff following the inquests of other prisoners who had died following being found hanging there. The reports were issued in May 2016, following the death of Sheldon Woodford in March 2015, in October 2016, following the death of Haydn Burton in July 2015, and in April 2017, following the death of Daryl Hargrave in July 2015.
Evidence was given at the inquest by the Head of Safer Custody at HMP Winchester that as of September 2017 only 47% of all staff at HMP Winchester were ACCT trained.
Solicitor Clair Hilder, a senior associate in the civil liberties team represented Mr Plumstead’s family at the inquest, she said: “This is the third inquest in the last 12 months where I have represented the family of someone who has taken their own life at HMP Winchester. One wonders how many more men have to die before the proper procedures and training are put in place? This case highlights the need for a national oversight body to ensure lessons are learnt from deaths in custody and action is followed through.
“The prison has still not made the improvements to staff training promised by the prison governor in April 2017; she claimed to be confident of having 80% of staff trained in suicide and self-harm prevention procedures by September 2017, yet we know that less than half of the staff have been adequately trained. National policy is that such training is mandatory for those in prisoner facing roles.”
Sean’s mother, Lisa Dance, attended the inquest and said upon its conclusion: “Our family is devastated by the death of Sean. Firstly, I would like to thank the coroner and the jury for the time and care they have taken in reviewing what happened to my son. The inquest process has been shocking and distressing. It was particularly hard to hear the evidence from the clothing exchange where Sean had been working prior to his hanging. I find it hard to believe that those responsible for Sean in the place of work had no proper training and that even today, one of them still hasn’t been trained.
“It was also hard to hear about the delay in the cell bell being answered, I know that I will forever wonder about what might have happened had staff got to Sean within the time they were supposed to. My hope now is that another family will not have to go through what we have, although the evidence we have heard at the inquest indicates that HMP Winchester does not learn lessons.”
Since Sean’s death there have been a further two self-inflicted deaths at HMP Winchester – one last month and one in May.
Deborah Coles, Director of INQUEST said: “The clear failings in Sean’s care identified by the jury are reflective of a pattern of failures at HMP Winchester, highlighted through numerous recent inquests. In the last five years there have been nine self-inflicted deaths in HMP Winchester, two of which followed Sean’s. The latest death was of a 25-year-old, and took place just last month. It is clear that learning and action after deaths is not happening. An urgent intervention at HMP Winchester, and across the crisis hit prison estate, is required if we are to stop the death rate rising higher.”
The inquest into the death of Sean Plumstead at Winchester Coroner’s Court opened on 9 October and concluded on 18 October. Counsel was Taimour Lay of Garden Court Chambers and the family were assisted by the charity INQUEST.
For further information, please contact:
Kerry Jack at Black Letter Communications
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