Lessons on jail death ‘must be learned’

In a report following last month’s inquest into the death of Andrew Needham from Grimsby in March 2011, Coroner Geoffrey Saul has recommended changes to systems of work in prisons to protect vulnerable and suicidal prisoners. Mr Saul called for staff to be given clearer procedures and faster access to prisoners’ medical records.

Mr Needham, who had a history of psychological problems and was on remand on a charge of wounding and possessing an offensive weapon, died after putting a plastic bag over his head and tying a ligature round his neck.

An investigation by the Prison Ombudsman said Mr Needham was vulnerable and rightly identified as being at high risk of self-harm by police and escorts to the prison. However, prison staff did not act on what should have been ample warnings and the ombudsman made a number of recommendations for action, including improvements to the way prisoners are assessed and managed on entering prison.

The inquest jury found that Assessment and Care in Custody Teamwork plans should have been opened on at least two occasions in February last year as Suicide and Self Harm forms were already active when Mr Needham entered prison.

They said: “On the balance of probabilities the failure to open ACCT plans contributed to Mr Needham’s death as he was not given the benefits of adequate mental health care.”

Lawyer Danielle Barney of Bridge McFarland Solicitors, which is acting for Mr Needham’s family, in a claim for breach of his human rights, said: “Family members very much hope that the coroner’s recommendations to HMP Hull and the prison’s healthcare service will help prevent unnecessary deaths in the future.”