A coroner has demanded to know why an opportunity to provide support for “vulnerable” prisoner Lee Rushton was missed before he was found hanged.
Andre Rebello said there had been “no effective mental health assessment” of the former Wigan labourer after he was brought into custody on January 22 last year for breaching bail conditions over a harassment charge.
Although an Assessment Care in Custody file was opened on the Marsh Green 25-year-old, which mentioned he had suicidal thoughts, and had self-harmed in the past, two separate referrals for a meeting to discuss his case at Liverpool’s Walton Prison had gone missing.
On the third day of a Liverpool Coroner’s Court inquest into Lee’s death, Mr Rebello questioned John McNeil, joint head of healthcare, specialising in drug dependency and mental health, as to how that could happen, but he could offer no explanation.
Mr McNeil said: “At the time the process was very fragmented, with people dealing with different things.
“It was not as effective as it could have been.
“Now we have an integrated approach.”
He added that had Lee been discussed at the single point referral meeting on January 26, a plan would have been put in place, which included one-to-one counselling, and psychiatric services.
While reproaching the services, Mr Rebello added: “That does not mean the outcome would have changed.
“We don’t know what would have altered his intention but the opportunity to do something meaningful was missed.”
The jury heard that during his first medical assessment, Lee admitted to injecting heroin daily before he was sent to prison and was taking diazepam for anxiety.
He was prescribed a daily amount of methadone and diazepam, and it was noted he presented no evidence of major withdrawal symptoms.
Three days before his death his medication was reduced slightly as it was making him drowsy.
It was noted this did not have an adverse effect on him.
Mr Rebello said Lee had ingested a legal high which had most likely been smuggled into prison.
He added that the night before he died he was agitated and argued with his cellmate.
He said: “They were separated and after a cup of tea he was fine.
“The next day he was dead. His behaviour and actions could be a combination of his mental health and possible effects of drug withdrawal.”
A report by Dr Haitham Nadeem, called as an independent expert in drug healthcare, criticised the assessment criteria by the substance misuse team.
He said Lee should have been under more frequent and intense nursing supervision and said he should have been transferred to a mental health wing.
Dr Julian Menoz, a substance misuse doctor with Merseycare NHS Foundation Trust, said: “There was already an ACCT mental health team involved. My assessment would not have added anything that was not already known.”