Inquest into death in prison finds contributory failures by prison and healthcare service

Thu, 10 Mar 2022

A jury has returned a conclusion of suicide and of numerous failings by a prison and its healthcare service, Practice Plus Group, following an inquest at which Philip Rule represented the family of the deceased.

Philip Rule represented the family of the deceased, instructed by Cormac McDonough and Guy Mitchell, assisted by Lottie Baldwin, of Hodge Jones and Allen.

Evidence had been heard over a two week hearing held at Newport Crown Court on the Isle of Wight, investigating the circumstances of the death of Duncan MacNeil in the island’s prison in October 2019.

HM Senior Coroner for the Isle of Wight, Caroline Sumeray, had ruled that Article 2 of the European Convention on Human Rights applied and that the inquest must therefore answer in what circumstances Mr MacNeil came by his death.

Having concluded that Mr MacNeil’s death was the result of suicide, the jury found that there were omissions or failures in:

  1. Welfare management by the prison;
  2. Support or monitoring by the prison;
  3. Support or monitoring by the healthcare service; and
  4. The recording and sharing of consideration of information by the prison and healthcare service.

It found that each of these omissions or failures caused or contributed to Mr MacNeil’s death.

Elaborating on its findings, the jury noted that there was an absence of the necessary welfare check that ought to have been conducted to ascertain Mr MacNeil’s wellbeing at unlock and lock-up before and after the lunch time.

In relation to omissions or failings in the support or monitoring by the prison, the jury accepted that there were five such failings:

  • Insufficient time allocated to prison “keyworkers” (and no management auditing of the performance of keyworker functions)
  • The absence of management support for keyworkers
  • The absence of offender supervisor contact with Mr MacNeil
  • The absence of a risk assessment (when there were adverse developments, including a refusal of parole), and
  • The absence of consideration of opening an “Assessment, Care in Custody and Teamwork” (ACCT) document (used to monitor prisoners at risk of self-harm and suicide).

These were failures that the jury found had probably contributed to Mr MacNeil’s death. The inquest had heard evidence from a keyworker who said that he was due to spend forty-five minutes a week with each prisoner under his supervision, but that this did not take place in practice. Indeed, there were few sessions and many months during which no keyworker could even be identified as allocated to Mr MacNeil.

The jury also identified failures or omissions on the part of the prison’s healthcare service, which is provided by a private company, Practice Plus Group. These included the failure to appoint a mental health nurse to Mr MacNeil’s case and the failure to carry out a mental health assessment of Mr MacNeil. There was further, in the jury’s view, a failure to record the outcome of multi-disciplinary team meetings on the healthcare service’s digital records in order to ensure that any necessary action could be taken following those meetings.

Finally, the issue of information sharing and recording was also considered by the jury. The jury had heard evidence relating to policies and practices governing the recording and sharing of information in the prison setting. This involved various digital and physical systems of recording information including the Prison National Offender Management Information System (P-NOMIS), prisoner medical records, and ACCT documents. The jury concluded that important information relevant to assessing a prisoner’s “at-risk” status was not communicated to the staff who should be made aware of it, in order to enable them to act in a prisoner’s best interests. The jury gave the example of risk factors set out in the Prison Service Instruction governing ACCT documents. These risk factors included the refusal of parole. Mr MacNeil had been refused parole in the months preceding his suicide.

Following the conclusion of the inquest, the Senior Coroner is considering the concerns that she may have that need to be included in a Prevention of Future Deaths report.

Philip Rule is Head of the Public Law Group.

Related articles

The inquest into the death of Robert Frejus concluded that failings by the prison and by prison healthcare possibly contributed towards his death. Robert died on 9 October 2018 at HMP Nottingham after self-harming. He was 29 years old at the time of this death....

Date: Wed, 27 Apr 2022
Permission to judicial review has been granted in a case where an Asylum seeker sought social services support under the Care Act 2014, through a referral made by the local police force in Croydon....

Date: Tue, 08 Mar 2022
The High Court has granted permission to bring the judicial review in R (Gorani) v HM Assistant Coroner of Inner West London and others (CO/490/2021)...

Date: Tue, 18 Jan 2022