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Inquest into death of 22-year-old man at HMP Winchester finds serious failings amounting to neglect
7 April 2017
by black letter communications on behalf of hodge jones & allen
An inquest jury has found neglect at HMP Winchester contributed to the death of Daryl Hargrave, one of four self-inflicted deaths at the prison in 2015
A jury at the inquest into the death of 22-year-old Daryl Hargrave, from London, has found that serious failings, amounting to neglect at HMP Winchester, contributed to his death. He had shown clear symptoms of psychosis over the three days before his death and had reported to staff that he had demons in his blood, telling him to harm himself.
Daryl was found hanging in his cell on 19 July 2015 having been remanded into custody only six days earlier.
Following a four-week inquest held at the Council Chambers in Winchester, the jury concluded that there was a failure by healthcare at the prison to provide treatment for Daryl’s psychosis and that this failure amounted to neglect.
The jury also recorded a catalogue of actions contributed to his death, including:
• the decision to put Daryl into cell 17 in the healthcare unit;
• the failure to put him under constant supervision;
• the failure to carry out a multidisciplinary ACCT (suicide and self-harm prevention measures) case review on 18 or 19 July;
• the absence of nicotine replacement therapy in the prison’s healthcare unit, and;
• a delay in providing fluoxetine, pregabalin and propranolol between 14 – 16 July.
Assistant coroner, Karen Harrold said she remained “gravely concerned” about the risk of future deaths at the prison and felt further steps were needed to reduce this risk. She intends to make a report to prevent future deaths at HMP Winchester. This will cover 13 areas including the quality of ACCT (suicide and self-harm prevention measures) documentation and audit processes, meaningful interaction between staff and those subject to ACCT training, and the documentation of self-harm incidents.
Daryl’s death was one of four self-inflicted deaths that occurred at HMP Winchester in 2015; it took place just a day after that of Haydn Burton, whose inquest concluded in September 2016. The jury in that case was also highly critical of the support given by staff to Haydn before he took his own life.
Daryl had a long history of self-harm and suicide attempts, and had suffered from mental health problems from a young age. He was remanded into HMP Winchester on 13 July 2015 after being arrested during the early hours the previous day. Upon arrival, there was a lengthy delay in Daryl receiving medication for his mental health problems. He was not given medication for three days because his GP records had not been reviewed, despite them being received promptly following his reception into prison.
On 15 July 2015, Daryl was placed on an ACCT (suicide and self-harm prevention measures) after telling a healthcare support worker that he had suicidal thoughts, was hearing voices and did not want to live. The next day he was seen by a mental health nurse who reported that he felt that demons were tormenting him and were telling him to kill himself. She described him looking over his shoulder and speaking to something that was not there saying “no I don’t want to” and “no go away”.
The nurse considered he was suffering from psychosis and made an urgent referral to the prison’s Community Mental Health Team (CMHT) but this was not considered an emergency by them and the appointment was scheduled for the following Monday - 20 July 2015.
The inquest heard from a Consultant Forensic Psychiatrist, Dr Dinesh Maganty, who said what the nurse had documented were as clear signs of psychosis as a nurse could document. His view was that someone acutely psychotic should be the highest priority and should have been urgently seen by a GP or psychiatrist. They could have given him medication to help with the anxiety and agitation caused by his psychosis.
This need for urgent medical care increased when, on 18 July 2015, Daryl cut himself in his cell. Daryl described to a nurse that he felt ground down by the voices and didn’t think he could cope with them anymore. This nurse told the inquest she requested he be placed on constant watch but this did not happen, both the prison’s constant observation cells were in use, and following a further assessment from a mental health nurse his observations were increased from hourly to half hourly. This later assessment was criticised by Dr Maganty as not being comprehensive enough and he expressed grave concerns that it was thought even the increased level of observations were adequate. Both Dr Maganty and a GP commissioned to evaluate the clinical care provided to Daryl felt he should have been placed on constant watch at this stage.
Daryl was transferred to the healthcare unit in an isolated cell, cell 17, away from the main corridor where other prisoners were located. The inquest heard that this cell was only used if it had to be, with one nurse describing it as the worst place to put someone who was suicidal, as it was “out of sight, out of mind”. It has since been taken permanently out of commission and is used as a store cupboard.
Daryl had no TV or radio, no one to talk to and Dr Maganty described it as akin to solitary confinement, giving evidence that it contributed to his distress and led to a further deterioration in his condition. He believed however, that the adverse effects could have been mitigated if Daryl had been placed on constant watch.
Daryl was unable to smoke in the healthcare unit as he had been able to on the wing. Nicotine patches which are easily available over the counter in the community were not available to him in prison without a prescription, which staff were unable to get at the weekend. Experts at the inquest expressed concerns about this basic treatment being unavailable and noted enforced nicotine withdrawal would have contributed to his stress and feelings of hopelessness.
He continued to express thoughts about killing himself to staff and at 3.11pm on 19 July 2015 was found hanging in his cell, having threaded his bed sheet through the observation hatch in his door. The observation hatch had been left open despite this being recognised as a ligature point. His scheduled 3pm ACCT observation had been missed and incorrectly noted as having been carried out.
Clair Hilder, civil liberties lawyer at Hodge Jones & Allen represented Daryl’s mother, Nicola Hargrave at the inquest, she says: “This is a tragic case of a vulnerable young man with severe mental health problems who was badly let down in prison. Not only did staff fail to keep him safe but the expert evidence heard at the inquest was that their actions increased the likelihood of Daryl taking his own life. He was reporting hearing voices, having suicidal thoughts and had cut his wrist, yet it is clear from the jury’s findings that those at the prison failed to provide Daryl with the basic medical care he urgently needed.
“He was insufficiently observed, was held in an unsuitable cell and was not even able to phone his mother when he was in crisis.
“Daryl’s death was the second that week at HMP Winchester, raising considerable concerns about the prison’s ability to ensure the safety of those in custody. The Governor gave evidence during the course of the inquest that in September 2015 only 41% of staff were adequately trained in suicide and self-harm prevention. Whilst this has now increased to 61%, progress has been too slow as a result of resourcing issues and the Governor has accepted that this is not good enough.”
Nicola Hargrave says: “All our family has been left devastated by Daryl’s death. He was a bright young man who had had a difficult childhood and had suffered from mental illness for many years. He had been in prison for only a few days and needed urgent medical attention. Over the last few weeks it has been incredibly hard to hear about the catalogue of failings by prison officers and healthcare staff at HMP Winchester and I sincerely hope that the prison will face up to the mistakes that were made and take action. I cling to the hope that Daryl’s death will at least help others.”
Clair Hilder also acts for the family of Haydn Burton and represented them at the inquest into his death last year. She has also been instructed by the family of a man who died at HMP Winchester in September 2016.
Daryl’s family is also represented by counsel, Taimour Lay from Garden Court Chambers and assisted by the charity INQUEST.
‘Lobbying that is based on thorough research and casework (such as that done by INQUEST), and focuses on specific issues, such as the deaths of children in custody, needs support.’
– New Philanthropy Capital, 'Trial and error: Children and young people in trouble with the law, a guide for charities'