Inquest Finds That Healthcare And Prison Failings Contributed To Death Of Chelmsford Inmate

Daniel Weighman, 38, told prison officers he was “hearing voices” just hours before he was found dead in his cell.

An inquest into the death of HMP Chelmsford inmate Daniel Weighman today concluded that it was probable that several failings of healthcare and prison staff contributed to his death on 6th January 2023. This is the ninth self-inflicted death at HMP Chelmsford since 2020, leading to widespread criticism of the prison and its treatment of inmates who are suffering with their mental health.

The jury delivered a narrative verdict, highlighting that it was probable that several failings, including, but not limited to, the following contributed to Mr Weighman’s death:

• The failure of Castle Rock Group healthcare staff to assess Daniel’s risks of self-harm/suicide in light of the information contained on SystmOne.
• The lack of adequate understanding of healthcare staff and prison officers about their duties under the Assessment, Care in Custody and Teamwork (ACCT) process.
• A serious failure in appropriate ACCT training for healthcare and prison staff at all levels.
• Daniel did not receive adequate support at HMP Chelmsford from prison and/or healthcare staff from 1st January 2023.

Daniel, from Westcliff-On-Sea, Essex, was the third eldest of eight siblings and was a family-oriented son, father, and brother. He cared deeply for his mother and siblings and would regularly cook for them and look after his younger brothers and sisters. After leaving school, Daniel worked as a labourer and moved out of his family home in his early twenties. He regularly visited to look after and spend time with his mum.

Daniel was on remand at HMP Chelmsford at the time of his death. His prison and medical records at the time of entry included that he had a history of psychotic symptoauditory hallucinations, for which he had received treatment when previously held at HMP Chelmsford. He also had a history of alcohol misuse; however, he was not placed under the care of the mental health team and was never referred to the team during his initial screening. An email sent to the head of the mental health department a few days after his induction to the prison, seeking a review of his mental health, was overlooked and Daniel was not reviewed by the mental health team at any point following his arrival to the prison in October 2022.

In December 2022, Daniel’s behaviour in prison started to change. He became increasingly agitated, which was noticed by friends, family, and the prison officers, and this led to one of his cellmates asking to be moved.

On 1st January 2023, Daniel reported to officers that he would self-harm unless he was seen by a healthcare professional. Daniel was able to speak with a paramedic, where he again expressed his intention to self-harm. Following these conversations neither the prison officer nor the paramedic took any steps to open an ACCT support plan. Daniel’s threats of self-harm were initially dismissed as a manipulative attempt to be transferred to the mental health unit.

On 3rd January 2023, Daniel reported to officers that he was “hearing voices” and asked to be moved to the healthcare unit. A Senior Officer then made a referral to the head of mental health at the prison; however, again this email was never picked up. Daniel persistently rang his cell bell throughout the day, asking when he would be moved to the healthcare unit. There were no steps taken to ensure Daniel was unable to harm himself whilst in his current cell, and later that day, he was seen with self-harm injuries.

Following this incident, an ACCT was opened, and Daniel was placed on hourly observation, the lowest level of support permissible when an ACCT is opened. Two hours later, Daniel was found ligatured and was taken to hospital – where he died three days later.

Chloe Weighman, Daniel’s sister, said: “Danny, at his core, was a kind and loving person, and while he made a few mistakes in his life, he never deserved this. HMP Chelmsford has taken Danny from us. If Danny was given the support he so desperately asked for, we would not be where we are today. He was repeatedly failed by the prison and healthcare service, who failed to carry out their basic responsibilities towards him, and we have paid the ultimate price for those failures.”

Gimhani Eriyagolla, the solicitor from Hodge, Jones & Allen representing Daniel’s siblings said: “We welcome today’s conclusion, and yet are unsurprised by these continued failures of HMP Chelmsford and CRG. Too many people have now died because of their careless and slapdash approach to the well-being and health of the men they are charged with looking after. If nothing else, we hope that Daniel’s case goes on to raise national awareness of the need for our prisons to make sure more lives aren’t needlessly lost through easily avoided errors. Urgent action is needed to improve and expand the mental health services within our prison system. We need to make sure those in our prison system receive the crucial support they desperately need and are entitled to.”