A coroner has ruled that neglect contributed to the death of a young Wigan man during his first stay in prison.
Lee Rushton, 24, was found hanged in his cell at HMP Walton in January last year. He had only been a remand inmate there for six days and his death came just minutes before he was meant to make a video link court appearance regarding a harassment charge for which he was due to stand trial.
After hearing evidence for seven days at Liverpool Coroner’s Court, a jury concluded that the young man from Marsh Green did not intend to take his own life.
In a comprehensive and highly critical narrative verdict, they found Lee died from 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 during Lee’s time in the prison’s care. The jury listed the following 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:
Numerous failures in carrying out the ACCT process, including 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 adequately and effectively 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.
Coroner Andre Rebello has compiled a Prevention of Future Deaths report in connection with the issues identified by the jury.
In a statement issued after the hearing, Lee’s family said they were devastated by his death but pleased that the jury “recognised the systemic failures in the care that was provided to him. They hope that the prison will now implement changes to ensure these failings are never repeated.”
Leanne Dunne, solicitor representing the family, said: “It is important that the failures in the level of care provided to prisoners are recognised and the jury’s findings in this case highlight some of these issues Not only do these failures have a devastating impact on families but also link in with the wider social issues regarding the fact that prisoners should at least be provided with the same level of medical care that they would be provided within the community.’
Deborah Coles, Director of INQUEST said: “At a time when prison reform is on the agenda, this case exemplifies everything that is wrong with the prison system. It is deplorable that a vulnerable young man in need of mental health support can die in this way where neglect and gross failures are identified as a contributory factor. Urgent and decisive action is needed now to prevent further deaths. This situation can no longer be tolerated.”