Lessons to learn from Lee tragedy

Jurors at Lee Rushton’s inquest last week issued a stinging series of criticisms against Liverpool Walton Prison for ignoring or failing to anticipate the first timer’s distress and vulnerability.

The Marsh Green 24-year-old, who had been remanded in custody after breaching bail conditions while facing a harassment charge, was found hanged in his cell just six days into his stay.

The prison has also recently been criticised by the Prisons and Probations Ombudsman over the case who has made a number of recommendations.

The Liverpool Coroner’s Court jurors ruled that Lee did not commit suicide but suffered an accidental death contributed to by neglect, along with a number of significant failings by the prison and healthcare staff.

The jury heard evidence that a real and imminent risk of self-harm or suicide was recognised on Lee’s reception into prison by the opening of an Assessment, Care in Custody & Teamwork (ACCT).

But it concluded the risk was not managed adequately and effectively and flagged up a number of issues at the prison:

* Failure to discuss Lee at the relevant mental health meetings despite being referred on two separate occasions;

* Failure to recognise his level of vulnerability as part of the ACCT process;

* Failure to explain fully the prison phone system which removed a major protective factor in him not being able to call anybody;

* Ineffective use of the cell share risk assessment, leaving Lee alone at a high risk of self harm/suicide:

* Lack of communication, not following procedures, missed opportunities to increase observations, not taking a multidisciplinary approach, lack of ownership of issues, missed opportunities to hold review meetings, and neglecting to record information on documentation;

* Inadequate management of drug dependency including missed treatments, inconsistent treatments, lack of continuity and lack of recording. The jury considered this more likely than not contributed to Lee’s intentions concerning self-harm or not;

* A failure to properly assess Lee’s mental health;

* A failure to properly investigate a prisoner assault on Lee days before his death despite Lee having expressed his fear to staff. The jury considered that it was more than likely that this incident added to Lee’s vulnerability given his mental state.

The jury concluded Lee was in a dependent position due to mental illness and incarceration. They stated there was a “failure to provide and procure basic medical attention” and there was a “gross failure” in his mental health care which could have saved or prolonged his life.

And a Prison Service spokesperson said today: “This is a tragic case and our thoughts are with the family and friends of Lee Rushton.

“The safety and welfare of people within our custody is a top priority and we take our duty of care to them extremely seriously.

“We accepted the recommendations of the Prisons and Probation Ombudsman’s investigation in this case and we will carefully consider the inquest findings to see what further lessons can be learned.”