Inquest conclusion highlights limited resources at HMP Norwich

A jury inquest into the death of 32-year-old Matthew Gray from Norfolk has concluded he died by misadventure, highlighting limits on prison staff’s time and resources in its conclusions.

Matthew was found hanging in his cell on 20 March 2017 and died in hospital on 22 March 2017. His death was one of three that occurred at HMP Norwich over a four-month period last year.

Matthew, who had a history of mental health problems and drug dependency, had voiced concerns for his safety in the run up to his death. He complained of being bullied by seven other inmates and was under threat due to debts he owed.

The jury sitting in front of Area Coroner, Yvonne Blake, found that evidence relating to specific individuals who Matthew was indebted to was not adequately communicated to relevant staff and that this could have significantly contributed to Matthew’s emotional state prior to his death.

They found that although there were systems and processes in place to share historical information about prisoners, evidence indicated that staff are limited by time and resource and often operate without full awareness of a situation. They concluded that officers operate as adequately as possible, given these limitations.

In the past Matthew had set light to his cell and been found with a ligature around his neck. He had also expressed to staff that he wished to end his life.

On 8 March 2017, Matthew jumped over the prison’s railings into netting below, explaining to officers that he was under threat from other prisoners that he owed money to. He was moved to segregation and at an adjudication hearing reported he was under threat, naming seven prisoners responsible for bullying him.

No action was taken to protect Matthew from this threat or to reassure him that he was safe. He was forcibly returned to the wing on 20 March 2017, where one of the prisoners that Matthew had identified was seen at his cell door. Shortly afterwards another prisoner reported to a prison officer that he had heard Matthew ripping up bed sheets and he was concerned Matthew may be making a ligature. Officers found that Matthew had blocked his observation panel, obstructed his cell door and was not responding when they spoke to him through the door. They left without attempting to force the door open.

They returned 16 minutes later to find Matthew hanging. He died in hospital the following morning.

The seven-day inquest examined why Matthew’s concerns for his safety heard in the adjudication were not followed up, why officers routinely failed to look up a prisoner’s history before carrying out risk assessments and why he was returned to the wing without addressing his fear of violence being used against him and without consideration of his underlying mental health needs.

The family were represented at the inquest by Alice Hardy of London solicitors Hodge Jones & Allen, and Ruth Brander of Doughty Street Chambers.

Speaking on behalf of the family, Alice Hardy said: “Matthew Gray was the first of three young prisoners to die at HMP Norwich between March and July last year. His inquest has highlighted the significant strain that prison officers were under due to a severe lack of time and resources. This meant that too little was done to protect Matthew from known risks to himself and from others. It is hoped that increases in resourcing and staffing levels are made so that desperate and vulnerable young men are properly protected.”

Hodge Jones and Allen also acted for 36-year-old Joe Bartlett from Colchester in Essex who died at HMP Norwich on 5th April 2017 after being found in his cell with a ligature around his neck. At his inquest the jury noted that procedures to reduce the risks of self-harm and suicide were not adequately followed, there was insufficient information gathering, and there was a failure to recognise the seriousness of the bullying to which Joe was subjected and to respond accordingly.

The family were also advised by the charity, INQUEST. Selen Cavcav, INQUEST caseworker, said: “Matthew’s history of attempted suicide and self-harm in custody, drug dependency and being subject to bullying made him particularly vulnerable. The only people who could keep him safe in prison were the prison officers. Yet on the day Matthew died they knew nothing about him, having never even read his records.

Prisons are inherently dangerous environments, ill-equipped to protect people from harm. Recent attempts at reform and improvements have done little to protect those in need, like Matthew and those who died after him in Norwich prison. Effective change can only come from a dramatic reduction in the prison population, and investment in diversion and community alternatives.”