Inquest into the death of Mr Satnam Singh, 6 to 10 January 2014 at the Coroner’s Court Birmingham

Tue, 14 Jan 2014

James Dixon has recently represented the family of Mr Satnam Singh in an inquest which found that there has been ‘a failure to implement timely mental health support for him’ following very disturbing signs.

Satnam Singh hung himself in a cell at HMP Birmingham on 23 February 2010. He was a 26 year-old Indian man who had lived in England since 2003. He was a meat factory worker and had a 2-year old son. For all but one week he had lived together with his family.  He spoke very minimal to no English and could not read or write. During the weeklong inquest the court heard that he had never been in prison before but was remanded into custody on 16 January 2010 and that he began to behave in a very bizarre manner such that prisoners and prison staff had no idea what was wrong with him. As at 20 February 2010 he had chewed electrical cables in his cell on at least two occasions but the prison did not see the need for a mental health assessment. On 21 February he exhibited extremely distressing behaviour and was taken to healthcare. An experienced prison officer said that he was one of the most upset prisoners she had ever seen. He had also tried to jump over the balcony on the 4th landing on the wing. He appeared to be petrified of being alone in a cell and could not understand why he was in prison.

A prison Governor who spoke his own language managed to calm him down, after he had been clearly indicating that he was minded to hang himself. A psychiatric nurse from healthcare said that he should be on constant watch but when he returned to his own wing he was not placed on constant watch (although he could not speak English, the prison staff satisfied themselves from observations from his behaviour that he was no longer an acute suicide risk).

All appeared calm on the following two days, though the mental health assessment he had on 23 February was undertaken without the benefit of any Punjabi interpreter at all. In the evening on that same day, after 9.30 pm he was found dead in his cell after he hung himself. At 10.12 pm he was pronounced dead.

The inquest involved the full procedural duty so as to respect the right to life under Article 2 ECHR.

The jury heard a considerable amount of detailed evidence and on 10 January 2014 concluded that it was suicide and that the following circumstances had lead to his death:

·       Communication difficulties relating to language barriers

·       A lack of appropriate professional translation support

·       A lack of communication between the departments involved in his case

·       Failure to implement timely appropriate mental health support for him following signs of erratic behaviour, major signs of distress, isolation and lack of understanding

The jury also highlighted communication with his family as an issue, the evidence being that he had no direct contact at all with his family between 16 January and 23 February though his family had tried to visit him.

Satnam’s Singh’s family was represented by James Dixon of No 5 Chambers and Mr Iqbal Singh Kang of Gurney Harden Solicitors. 

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