A jury has blamed prison workers for failing a troubled inmate who died after hanging in his cell.
After hearing six days of evidence at Andrew Fenn’s inquest, they said that “failings probably contributed to his death” in HMP Lowdham Grange.
Mr Fenn, 29, had a history of cutting himself and had put a ligature around his neck months before his death on October 4 last year.
Shortly before, he had been forced into his cell for breaking prison rules. Staff left him alone as they were about to open an ACCT, a procedure to closely check vulnerable inmates.
The 11-member jury returned a narrative conclusion, saying that it was “unclear whether Andrew meant to go through with an act of suicide”.
But they said: “Previous history of self-harm, triggers and patterns of behaviour when Andrew was angry or in a low mood should have been recognised.
“The cell should have been thoroughly searched for self-harm and suicide risks. Andrew should not have been left alone while the ACCT was being opened.
“The failings probably contributed to Andrew’s death.
“There were systematic failures to follow guidelines,” said the jury, which was critical of health care cover.
The jury highlighted an error in screening Mr Fenn when he arrived at the jail six months earlier, saying: “This resulted in insufficient information on Andrew’s medical history, including his mental health.
"There is evidence to suggest numerous opportunities for multi-disciplinary case reviews were missed.”
During the inquest, some prison officers said they were aware that Mr Fenn cut himself but did not know that he had previously used ligatures.
The jail is run by private firm Serco. Director Mark Hanson, the senior manager, said that more could have been done to help Mr Fenn.
This included providing a better “care map” and doing more to find him work.
He felt that mental health workers should have been “in the centre” of multi-disciplinary efforts and that more efforts could have been made to improve links with Mr Fenn’s family.
Mr Fenn claimed to have been bullied over a drug debt and blocked his cell window shortly before he was found hanging. He died in the QMC.
Detective Constable Natasha Ullyatt said a police investigation revealed no suggestion of “third-party involvement”.
