Jury Finds Neglect And Multiple Serious Failures Contributed To The Death Of IPP Prisoner

Before HM Assistant Coroner Caroline Topping.
At Woking Coroner’s Court, Station Approach.
11-29 November 2024.

An inquest jury investigating the death of Haydar Jefferies, an IPP prisoner who died a self-inflicted death on 5 March 2023, has found that a score of failures contributed to his death, including a gross failure by prison staff to procure him basic medical attention amounting to neglect.

Haydar Jefferies, a fifty-year old publican from London, was recalled to prison in January 2022 on his IPP sentence. Due to the nature of the IPP sentence and delays in Parole Board decision-making, he remained in prison at the time of his death, despite all charges against him having been dropped some nine months prior. In the weeks leading to his death, Haydar’s mental health drastically deteriorated, suffering from a serious psychotic illness which went entirely unheeded and untreated by the staff responsible for his care.

The inquest heard how, by 28 February 2023, Haydar was acutely psychotic, found by officers in his cell flushing his head down the toilet, naked on all fours, and barking like a dog. Despite this, healthcare staff were not called to attend, nor was external medical attention sought. Haydar was subsequently discovered in the early hours of 1 March 2023 having ligatured. He died several days later following hospitalisation.

In a highly critical and wide-ranging narrative conclusion, the jury found that there were numerous failures by custodial staff to record, escalate and act on concerns raised over Haydar’s deteriorating presentation which were causative of his death. Moreover, and most starkly, that these failures were so serious as to amount to neglect.

Between his initial IPP release and subsequent recall, Haydar had spent nine years in the community quietly rebuilding his life. He had married and set up his own pub and B&B in Oxfordshire with his husband, who sadly passed away in 2021.

Only a few months into Haydar’s recall to HMP Bullingdon, in early 2022, it was confirmed that the allegations against him were no longer being pursued. Haydar however remained in prison for another year, awaiting authorised release by the Parole Board. An application to determine his release on papers was declined, and various delays led to his oral parole hearing being rescheduled to March 2023. The jury duly found that Haydar’s IPP status and the delays in his parole hearing materially contributed to the development of his subsequent psychosis.

Haydar was transferred to HMP Coldingley on 28 December 2022. On 12 February 2023, he requested to be segregated for his own safety. Expert evidence heard from a consultant psychiatrist was that, following his segregation, Haydar’s mental health steeply deteriorated such that, by around 18 February 2023, he was suffering from a severe psychotic illness which required timely psychiatric assessment, treatment and transfer to a prison with a healthcare wing.

The jury heard that, during his subsequent 10 days in segregation, Haydar made multiple concerning comments to both prison officers and his family symptomatic of his deteriorating ill-health. This included his intensifying delusional beliefs that prison officers were colluding with prisoners to sexually abuse and kill him, and that they were pumping gas into his cell. Haydar also progressively self-isolated, to the extent that, by 28 February 2023, he was refusing his regime entirely.

Haydar’s evident deterioration in this period prompted his family to make numerous phone calls into the prison, relaying what he was telling them and their serious concerns over his welfare. None of these calls however were appropriately documented in the prison records, nor were they passed on to the Mental Health Team.

Moreover, despite prison officers’ own concerns about Haydar, with several expressly recording the need for a referral to the Mental Health Team, this was never actioned. This meant that, before 28 February 2023, mental health staff were not made aware of any of the serious concerns over Haydar’s deteriorating presentation.

By the evening of 28 February 2023, Haydar was in the throes of a psychotic crisis. However, despite noting ‘major concerns’ over his mental health, custodial staff failed to seek any medical attention or even to notify healthcare. Haydar ligatured early the next morning, the day before his long-awaited parole hearing.

The jury concluded that a host of failures were causative of Haydar’s death:

• The serious failure by custodial staff to record risk-relevant information in respect of Haydar’s presentation, including raised by his family and observed by custodial staff directly.
• The attendant failure to ensure that such information was shared between custodial staff and escalated to clinical staff.
• The serious failure by custodial staff to refer Haydar to the Mental Health Team from 18-27 February 2023.
• The failure by the Mental Health Team to undertake a substantive mental health assessment of Haydar on 28 February 2023 following the (only) referral by officers that morning and subsequent segregation review.
• The response by the custodial staff to finding Haydar floridly psychotic on the evening of 28 February 2023, including the serious failures to place him on constant supervision and to take him to an external place of safety.

The jury went on to find that the failures by prison staff to procure medical attention for Haydar, both in the ten days leading to, and on the evening of, 28th February 2023, when Haydar suffered a further and acute deterioration in his mental state, amounted to neglect.

In addition, the jury concluded that the absence of any policy governing the recording and dissemination of information from concerned family members amounted to a systemic failure on behalf of Ministry of Justice. A range of other factors were also identified as possibly contributory to death.

Zhora Jefferies, Haydar’s mother, said: “After creating a wonderful life in the community, it is devastating to have witnessed how Haydar’s life was completely destroyed by the nature of his IPP sentence and the extensive delays he experienced when waiting to be released from prison.

“We had to watch our beloved son, brother and father succumb to the fear and paranoia that he was suffering with in the final weeks of his life. We, and Haydar himself, were all crying out for help and it was falling on deaf ears. It is so painful to know that he had been feeling so scared and alone and it has been completely shocking to learn of the lack of care and attention that had been afforded to Haydar when he was most in need.

“Nothing can be done to bring Haydar back but our biggest hope is that lessons can be learned from his experience so that no other family has to go through the horrendous loss that we have suffered. Haydar brought so much love to our family and we will always be grateful for the time we had with him. We will be forever grateful to the jury for considering the case with such diligence and for returning such a damning and detailed conclusion.”

Cormac McDonough, a civil liberties solicitor at Hodge Jones & Allen, who represented the family at the inquest said: “It is extremely rare for a jury to reach a finding of neglect in this context, which demonstrates how fundamentally failed Haydar was while under the care of prison staff at HMP Coldingley.

“It was evident that Haydar was suffering due to the unjust circumstances of his IPP recall and that this contributed to his deteriorating mental state. Staff at the prison failed entirely to recognise his deterioration and to take appropriate steps to keep him safe. His family made repeated attempts to get Haydar the help he patently needed, after receiving multiple distressing phone calls, but no action was taken.

“Haydar deserved better than this. We welcome the highly critical narrative conclusion by the jury and hope lessons can be learned from the catastrophic failings which resulted in Haydar’s death.”

The family were represented by Cormac McDonough and Megan Finnis of Hodge Jones & Allen solicitors, and Laura Profumo of Doughty Street Chambers.