Inquest jury concludes that multiple failures contributed to death at HMP Nottingham

Before H.M. Assistant Coroner, Miss Laurinda Bower
Nottingham City and Nottinghamshire Coroner’s Court, The Council House, Old Market Square, Nottingham NG1 2DT
Inquest heard between 26 February and 6 March 2020

Benjamin Ireson, known as Ben, was found hanged in his cell at HMP Nottingham on 13 December 2018. He was 31 years old. The inquest into his death concluded that multiple failures in the systems designed to keep him safe – described as “woeful” and “shocking” by the Coroner – contributed to his death.

Ben’s was the twelfth self-inflicted death at HMP Nottingham between June 2016 and December 2018.

The current Governing Governor of HMP Nottingham, Phil Novis, gave evidence at the inquest. Mr Novis, who took up the role in July 2018, described the prison as “absolute chaos”. He stated there were “no systems in place”, described the prison as “horrendous” and told the jury: “it is difficult to describe how bad it was”. He acknowledged that improvements by December 2018, including a reduction in prisoner numbers of 20% (from 1000 to 800), “had not come quickly enough for Ben”, and stated: “there were management failures at all levels up to and including me”.

In January 2018, after an announced inspection of HMP Nottingham, Her Majesty’s Inspectorate of Prisons (HMIP) invoked the Urgent Notification process – the first prison in the country to have the process invoked. HMIP highlighted high levels of self-harm and repeated failures to achieve or embed improvements following previous recommendations made by the Prison and Probation Ombudsman.

Ben was a remand prisoner who arrived at HMP Nottingham on 16 October 2018. He told staff he had a history of anxiety, had previously attempted suicide and wanted a cellmate as he felt isolated. Ben was referred to the prison mental health team and should have been seen within five days. In fact, he was not assessed for a further four weeks, by a trainee member of staff who did not know Ben and had not been provided with any information about him.

A week later on 22 October, Ben reported to prison staff that he felt under threat and that his possessions had been stolen from his cell three times. He stated that he felt like slashing his wrists before someone else did because he did not feel safe on B wing.

Prison staff started Prison Service suicide and self-harm prevention procedures (known as ACCT), which is meant to support prisoners and reduce their risk of self-harm and suicide. However, this monitoring was stopped only two days later, and at the inquest prison staff accepted that none of the issues identified had been resolved when Ben’s ACCT was closed. Ben was moved to a different cell on the same wing only nine doors down.

On 13 November, Ben attended court by video link. He pleaded not guilty to the charges against him and was further remanded in custody with a trial date five months later in April 2019 – although staff on the wing were not informed of this.

On 15 November 2018, a review of Ben’s phone calls (which should have been checked every three days) noted that he had repeatedly been expressing suicidal ideation and a desire to self-harm, including that he had tried to hang himself. This information was not passed to any staff on Ben’s wing, and, contrary to Prison Service procedures, ACCT procedures were not re-started.

An officer who reviewed Ben on 18 November (the ‘ACCT post-closure review’, which took place three weeks late in Ben’s case) was not aware of Ben’s phone calls, and despite noting that Ben was not engaging in any activity or employment, there was no evidence that any further support was offered to him.

On 9 December, Ben was moved to another cell on the same wing with no cellmate, and remained alone until his death.

On the evening of 12 December 2018, after he was locked into his cell, prison CCTV showed that prison staff walked past his door without checking at all on Ben (again contrary to Prison Service procedures). At 5.45am on 13 December 2018, an operational support grade (OSG) noticed that Ben had covered the observation panel in his cell with toilet paper, and saw that he was hanging from his wardrobe.

Ben was cut down and cardiopulmonary resuscitation (CPR) was started, but he was pronounced dead at 6.00am by paramedics who attended. A number of ligatures made from bed sheets and towels were discovered in his room.

After a seven-day inquest the jury concluded that the following issues contributed to his death:

• A referral to mental health on Ben’s first day at the prison was not acted upon until four weeks later, outside of the 5 day standard;
• A missed opportunity to help Ben by failing to monitor his telephone calls (and thereby be alerted to his suicidal ideation);
• Cell moves that left Ben isolated;
• Multiple failures in the system designed to protect Ben from suicide and self-harm (known as ACCT), including:
  • A failure to record any risks, triggers or actions to mitigate Ben’s risk of suicide and self-
    o harm;
  • Premature closure of Ben’s ACCT, without a case manager or personal officer assigned to
    o him;
  • A lack of information sharing and poor record-keeping, which led to an inadequate
    o assessment of Ben’s risks of suicide;
  • Insufficient training of prison and healthcare staff.

The Prison and Probation Ombudsman (PPO) investigation into Ben’s death was highly critical of HMP Nottingham. The PPO stated it was “very concerned to find the same failings again in Mr Ireson’s case, as well as in two previous self-inflicted deaths at the prison in October and November 2018”, and noted that “the lessons from previous investigations are simply not being learned”.

Following the jury’s conclusion, the Coroner, Laurinda Bower, said:
“The circumstances of Ben’s death are quite shocking. There have been failings in Ben’s care from the moment he arrived right up until his death which contributed to his death. On 13 December 2018, the very systems that should have been put in his place to protect him, failed him. The prison failed to follow national guidelines, and fell woefully short of what was expected. This was compounded by being the last in a long line of cluster of deaths at HMP Nottingham. All shared similar themes and issues. I was deeply concerned to hear repeatedly from witnesses that they had not read entirety of PPO report. This was a fundamental document in this case and a fundamental document to learn from the past mistakes and failures.”

Wayne Ireson, Ben’s brother, said:
“The Coroner and the jury acknowledged that Ben was let down at every single stage of his time in HMP Nottingham. We were devastated to hear the shocking evidence of how badly Ben was failed. Despite being directly criticised by the Prison and Probation Ombudsman, three senior prison officers had not even read the PPO report into Ben’s death before the inquest. We were told that improvements have been made at the prison since Ben’s death, but we question how effective these can really be and whether lessons will actually be learned. We are concerned that other families will end up in our position.”

The family is represented by INQUEST Lawyers Group members Jocelyn Cockburn, Claire Brigham and Aston Luff of Hodge Jones & Allen, and Tom Stoate of Garden Court Chambers.

The family’s solicitor, Aston Luff of Hodge Jones & Allen, said: “Ben’s death has highlighted yet again how deep and systemic the failures at HMP Nottingham are. Nearly every single member of staff working at the prison who appeared at the inquest admitted to have failed Ben in some way. Ben’s death was not as a result of one individual error. Instead, failures and missed opportunities to support Ben marked virtually every stage of his two-month detention. The evidence at the inquest made it clear that our prison system is putting vulnerable lives at risk.”

Deborah Coles, Director of INQUEST, said: “Nottingham prison has been subject to unprecedented levels of scrutiny since the year prior to Ben’s death. Yet not enough was done to address the serious issues identified by the Inspectorate, Ombudsman and at previous inquests. Ben died as a result of this failure.

“We simply cannot wait any longer for substantial and sustainable change in prisons. An independent national oversight mechanism to follow up on recommendations arising from deaths is urgently required. How many people have to die preventable deaths before this happens?”

The other interested persons represented at the inquest were HM Prison and Probation Service and Nottinghamshire Healthcare NHS Foundation Trust.

The inquest was heard before H.M. Assistant Coroner at Nottingham City and Nottinghamshire Coroner’s Court, The Council House, Old Market Square, Nottingham NG1 2DT.

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