Category Archives: Inquests
Holme House Prison Damned By Inquest Jury
In a damning verdict returned late on Thursday 13 June, the jury in the inquest into the death of Andrew Hall on 27 March 2009 found that he took his own life whilst the balance of his mind was disturbed, contributed to by neglect.
This is the third short form neglect verdict returned following a self inflicted death at Holme House prison.
Following three full weeks of evidence, the lengthy jury verdict listed 21 separate failures of Andrew Hall’s care and treatment at HMP Holme House. These included failures in risk assessment and risk management, and serious failures in communication.
Andrew served part of his sentence at HMP Kirklevington. Whilst there, he had attempted suicide by cutting both wrists. Following a period of hospitalisation he was transferred to Holme House prison on an open ACCT (Assessment, Care in Custody, and Teamwork – the system used for prisoners who are at risk of self harm), which was subsequently closed. The jury concluded that this ACCT should not have been closed. Following the (improper) closure of the ACCT, on 23 March, Andrew was further assessed by a psychiatrist who considered him to be psychotic and at significant risk of self harm. Despite this, no ACCT was re-opened, a clear failure identified by the jury. The jury found that none of the nurses in the subsequent four days had read the psychiatrist’s documented assessment. As a consequence, he was not afforded the level of observations, interaction and care necessary.
As a result, despite being in a camera cell, he was not being properly observed when he first inflicted a wound to his neck four days later. The jury concluded that the failure to observe and interact contributed to his death. In a devastating criticism, the jury also found ‘there was an opportunity for the staff to intervene between the time when he inflicted a wound to the vein in his neck and the time when he inflicted a wound to the artery in his neck’. This period lasted around 20 minutes, during which blood could be seen on CCTV on the floor of the cell.
The full verdict is available from INQUEST.
At the conclusion of the inquest, the deputy coroner indicated that he would be reviewing recommendations made following previous inquests into deaths at HMP Holme House before drafting his own, with specific reference to continuing failures of record keeping and communications between discipline staff, nursing staff and the mental health in-reach team. Since Andrew Hall died, there have been five further self-inflicted deaths at HMP Holme House.
Paula Davidson, Andrew’s partner said:
“The verdict today has proven Andrew’s death was unnecessary and if individuals had carried out their roles there would not have been failings in his care which resulted in Andrew’s death
“There have been a number of deaths before and after Andrew’s death and we hope that lessons have been learned from today’s verdict which the jury have returned.
“I would not have the truth for the family and also for our little girl today if it had not been for the support from INQUEST and I would like to thank them and Fiona Borrill and Imogen Hamblin from Lester Morrill solicitors and Sean Horstead from Garden Court Chambers for all their support throughout this four year experience.”
Deborah Coles, co-director of INQUEST said:
“Had greater care been taken been taken of Andrew this tragic and disturbing death might not have happened at all.
“The fact that this is the third neglect verdict since 2004 at HMP Holme House should be a wake up call to the prison service. Moreover, that there have been five further self inflicted deaths there since Andrew Hall died in March 2009 suggests that little has been done to address the issues raised at this and previous inquests.
“It is crucial for the safety of all prisoners at Holme House that these failings are addressed as a matter of urgency.”
The family is represented by INQUEST Lawyers Group members Fiona Borrill and Imogen Hamblin from Lester Morrill solicitors and barrister Sean Horstead of Garden Court Chambers. The same team represented the families of the two other self-inflicted deaths at HMP Holme House where neglect verdicts were returned at inquest.
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Notes to editors:
1. Full background on Andrew Hall’s death can be accessed here
2. The full jury verdict is available from INQUEST. Please contact Hannah Ward.
For further information, please contact: Hannah Ward, Communications Manager at INQUEST on 020 7263 1111/07972 492 230 or hannahward@inquest.org.uk
INQUEST provides a general telephone advice, support and information service to any bereaved person facing an inquest and a free, in-depth complex casework service on deaths in custody/state detention or involving state agents and works on other cases that also engage article 2 of the ECHR and/or raise wider issues of state and corporate accountability. INQUEST’s policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths occurring.
Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.
Cell death after ‘Legal High’
A former public schoolboy detained after taking a “legal high” died from a cardiac arrest after he was found in his police cell, an inquest jury ruled today.
James Herbert, 25, died almost three years ago after he was held under the Mental Health Act by Avon and Somerset Police.
Mr Herbert, who started smoking cannabis as a teenager and also took cocaine, ketamine, ecstasy and LSD, had taken the NRG-1 drug when he was seen acting strangely in Bath Road, Wells, Somerset on the evening of June 10, 2010.
He was restrained by police, placed in the back of a patrol van and driven more than 27 miles to Yeovil police station before being carried on a blanket into a cell, where he was left on the floor naked.
Mr Herbert was later found to be unresponsive and was taken to Yeovil District Hospital by ambulance where he was declared dead.
Following a three-week hearing at Wells Town Hall where an inquest jury heard from 34 witnesses and saw 30 written statements, a narrative verdict was returned by the panel.
They said the data recover engineer, who lived in Wells, died from “cardio-respiratory arrest in a man intoxicated by synthetic cathinones causing acute disturbance following restraint and struggle against restraint”.
“At 9.21pm on June 10, 2010 James Herbert died at Yeovil District Hospital following a cardiac arrest whilst detained at Yeovil custody suite,” they said.
“James Herbert was detained under Section 136 of the Mental Health Act and he was intoxicated by synthetic cathinones, he struggled violently against necessary restraint, he displayed acute behavioural disturbances and these factors probably contributed to his death.”
The jury also highlighted factors that may have contributed to Mr Herbert’s death, such as the lack of communication between police officers about Mr Herbert’s mental health, drug use and previous incidents; the failure to call for medical assistance while he was being taken to the police station; and the need for closer monitoring of him during that journey.
East Somerset Coroner Tony Williams said he would be writing to the chief constable of Avon and Somerset Police to highlight those issues raised by the jury.
“I do intend to write a report to the chief constable. I will not be making recommendations,” the coroner said.
“I should say that Avon and Somerset Police have previously responded to a number of recommendations as highlighted by the IPCC investigation into James’s death and it is gratifying to hear that some action has been taken in advance of this process.”
Speaking after the verdict, Mr Herbert’s parents, Tony Herbert and Barbara Montgomery, criticised the police.
“We are pleased the jury has recognised the serious failings of the police officers in their duty of care towards James,” they said.
“Evidence throughout the inquest has shown that had the officers responded differently, and treated the situation as a medical emergency, there is every likelihood that James would have survived his ordeal and still been with us today.
“This has been an intense and exhausting few weeks and the combative approach of Avon and Somerset Police, not to mention their unwillingness to admit wrongdoing, have been hard to bear.
“We can only hope now that lessons will be learned and James’s tragic death may help to make it a safer world for others, particularly for the vulnerable and those struggling with mental illness.”
Chief Superintendent Nikki Watson, of Avon and Somerset Police, said: “James’s death was a tragedy and our thoughts and sympathies are with his family.
“This case reinforces the dangers of legal highs.
“My officers were faced with a very difficult situation and in challenging circumstances they did their very best to protect James and the wider community.
“Police stations are not the most appropriate place of safety for people detained under the Mental Health Act.
“However, on many occasions it is often the only option available to us.
“We have taken note of the coroner’s helpful comments about communication, risk-assessment and places of safety.
“We will now reflect on how to improve our service in these challenging, but thankfully rare, situations.”
Following the inquest, the Independent Police Complaints Commission revealed it had “found a case to answer” for misconduct for an acting inspector, the custody sergeant and two police constables but the Avon and Somerset force had decided not to take disciplinary action.
The watchdog said it has also made a number of recommendations to the force following this incident.
“Avon and Somerset Constabulary held misconduct meetings for these officers and decided that the officers would not face misconduct sanction,” an IPCC spokesman said.
“The legislation governing police misconduct gives the employing force the decision on what sanctions, if any, to apply and the IPCC has no powers to direct outcomes.”
IPCC Commissioner Rachel Cerfontyne said: “My condolences go to Mr Herbert’s family and friends at this difficult time for them.
“I have offered to meet them and would like to do so before the IPCC publishes its investigation findings.”
Cell Death Inmate – Like A Tornado
The mother of a young man found hanged in his cell in Buckinghamshire has told an inquest that she was worried he would not be able to cope with being locked up.
Billy Spiller, 21, who was serving a three-and-a-half year sentence at a young offenders’ institution, had a history of self harming and had been diagnosed with Aspergers Syndrome and attention deficit hyperactivity disorder (ADHD) as a teenager, Buckinghamshire Coroner’s Court in Beaconsfield was told.
His mother Dawn said he started to injure himself from the age of nine and would sit on railway tracks near their home or drink white spirit when upset.
He left school at the age of 15 due to his difficult behaviour and went to work as a roofer with his father, Nick, but that came to an end when he jumped from scaffolding onto the roof of a double decker bus “for no reason”, Mrs Spiller said.
It appeared Spiller, who was 6ft 6in tall, sometimes lacked “an appreciation of danger”, Buckinghamshire Coroner Richard Hulett noted.
Spiller was given a three-and-a-half year sentence for his crime, details of which have not been revealed to the inquest, in December 2009, and had been in custody since July 2008. He entered Aylesbury Young Offenders’ Institution (YOI) in July 2010.
Mrs Spiller said: “I was very worried about Billy being in prison. I was worried they wouldn’t be able to cope with him.”
She had been allowed to sit with Billy, who was prescribed medication for his conditions, in police cells and in court.
“I knew he would not cope with being locked up and that’s why I was so worried,” she added.
Mrs Spiller described her son as “very impulsive” young man.
“He was so determined and headstrong,” she said. “Billy was like a tornado. He was always on the go.”
He would repeatedly kick and punch the walls of his cell at Aylesbury YOI and on the morning of his death was frustrated at not having enough money to call his girlfriend, the inquest heard.
When a prison warder checked on him at 1pm on November 5, 2011, Spiller said he was feeling better, after being allowed to make the phone call.
However, when the same warder looked in on Spiller’s cell through an observation window just over an hour later, she saw him hanging and immediately called over another prisoner to help bring him down.
Spiller was rushed to hospital but was pronounced dead on arrival. A pathologist gave the cause of death as suspension.
Death in Custody – Inquest Notice
INQUEST INTO THE DEATH OF 21 YEAR OLD BILLY SPILLER AT HMYOI AYLESBURY BEGINS MONDAY 22 APRIL
Monday 22 April 2013 at 10am
Before Coroner Richard Hulett
Sitting at Buckinghamshire Coroner’s Court, 29 Windsor End, Beaconsfield, HP9 2JJ
Billy Spiller was aged 21 years old when he died on 5 November 2011. He was found hanging in his cell at HMYOI Aylesbury.
During his childhood Billy was variously diagnosed with learning difficulties, autism and attention deficit hyperactivity disorder (ADHD). He self harmed as a child and first used a ligature when he was 16 years old.
In January 2010, whilst in HMYOI Aylesbury, Billy was found hanging in his cell. He was found and cut down and sustained no serious injuries. He was released on licence in October 2010 but recalled soon after and arrived back at HMYOI Aylesbury in February 2011. Following his return Billy repeatedly threatened to self harm. He was referred to the mental health in-reach team and a psychiatrist. Billy was also subject to an ACCT (Assessment, Care in Custody, and Teamwork – the system used for prisoners who are at risk of self harm).
In October 2011 Billy again threatened to self harm and on 3 November 2011 he threatened to make a noose. On 5 November Billy became distressed when he was unable to speak with his girlfriend. He punched the walls and asked to be constantly observed because he felt like killing himself. He was given a phone call to his girlfriend. At the end of the call both Billy and his girlfriend were in tears.
That afternoon Billy was found hanging in his cell at 2.17pm and, despite attempts to resuscitate him, he was pronounced dead at 3.08pm.
Billy’s family hope that the inquest will address the following issues:
- The care given to Billy by the mental health staff at HMYOI Aylesbury
- The ACCT process, assessments of risk of suicide and recognition of self harming behaviour.
- How the prison dealt with Billy’s threats to hang himself.
- Information the prison had on Billy’s history of mental health difficulties and the medication he had been prescribed previously.
- Prison staff training on dealing with prisoners with complex mental health needs.
Dawn Spiller, Billy Spiller’s mother said:
“After having to wait for nearly a year and a half to find out what happened on that tragic day, we hope to get closer to the truth and find out exactly what went so terribly wrong.
“We would like answers as to why my son had to lose his life in a state-run establishment that should have been protecting his wellbeing.”
Deborah Coles, co-director of INQUEST said:
“This is another troubling death in prison of a very vulnerable young man with a history of self harm and mental health needs that warrants wide ranging scrutiny.”
Billy Spiller was the second young man to take his own life in HMYOI Aylesbury in 2011. Seven young men have taken their own lives there since 2000.
INQUEST has been working with the family of Billy Spiller since his death in November 2011. The family is represented at the inquest by INQUEST Lawyers Group members Nancy Collins from Irwin Mitchell solicitors and barrister Stephen Cragg QC of Doughty Street chambers.
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Notes to editors:
For further information, please contact Hannah Ward, Communications Manager at INQUEST on 020 7263 1111 / 07972 492 230.
INQUEST provides a general telephone advice, support and information service to any bereaved person facing an inquest and a free, in-depth complex casework service on deaths in custody/state detention or involving state agents and works on other cases that also engage article 2 of the ECHR and/or raise wider issues of state and corporate accountability. INQUEST’s policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths occurring.
Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.
Death In Custody Inquest
Melanie Beswick
INQUEST INTO THE DEATH OF MELANIE BESWICK AT HMP SEND TO BEGIN THURSDAY 11 APRIL 2013
Thursday 11 April 2013 at 10am
Before HM Coroner for Surrey Richard Travers
Sitting at HG Wells Conference Centre, Church Street East, Woking, Surrey, GU21 6HJ
Melanie Beswick was 34 years old when she died on 21 August 2010. She was found hanging from a ligature made from shoelaces attached to the window of her cell in HMP Send.
In March 2009 Melanie was given a nine month prison sentence for fraud. This was her first offence. Melanie had a long history of depression and self harm, and self harmed on several occasions during her first period of imprisonment. Confiscation proceedings were brought and following her release Melanie was ordered to repay the money she took within 6 months or serve a further 12 month prison sentence in default. Short of selling the family home and making her husband and two young children homeless Melanie could not repay the money in time and was sent back to prison by the court.
She self-harmed on several occasions during her imprisonment and was subject to an ACCT (Assessment, Care in Custody, and Teamwork – the system used for prisoners who are at risk of self harm) on three occasions. She had also reported bullying on several occasions, and expressed fear that she would not be able to repay the money and so face further imprisonment. On the day of her death, she had been found unresponsive and motionless in her cell and, despite no obviously signs of physical ill health, was taken to hospital, where she became agitated and tried to harm herself several times. The doctor eventually discharged her but instructed that she was at high risk of self harm and needed constant observation and mental health input.
Despite this, on Melanie’s return from hospital that afternoon the duty governor decided that she did not need an ACCT or monitoring. Apparently unknown to him another officer had already begun the process but she was only placed on hourly observations. At about 7.45pm Melanie asked to speak to a Listener (prisoners trained by the Samaritans to support other prisoners in distress) but was told to wait because the on-duty Listeners were busy with other prisoners. At 8.35pm, she was found hanging in her cell and despite attempts to resuscitate her was pronounced dead at 10.02pm at hospital.
Her family hopes the inquest will address the following issues:
- · What HMP Send should have known about Melanie’s medical history
- · The ACCT process
- · The medical care Melanie received in HMP Send and her undiagnosed underlying mental health condition
- · How the prison dealt with Melanie’s allegations of bullying
- · Information Melanie was given about her sentence
- · The care she received at hospital on the morning of the day of her death
- · Information breakdown between the hospital and the prison
- · The decision of the Deputy Governor not to instigate ACCT monitoring
- · The Listener scheme
- · The provision of first aid by prison staff
Melanie’s husband, two young daughters, mother and step-father are represented by INQUEST Lawyers Group members Jo Eggleton of Deighton Pierce Glynn and Jesse Nicholls of Tooks Chambers.
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Notes to editors:
For further information and a photograph of Melanie, please contact Hannah Ward, Communications Manager at INQUEST on 020 7263 1111 / 07972 492 230 or hannahward@inquest.org.uk
INQUEST is an independent charity that provides a general telephone advice, support and information service to any bereaved person facing an inquest and a free, in-depth specialist casework service on deaths in custody/state detention or involving state agents and works on other cases that also engage article 2 of the ECHR and/or raise wider issues of state and corporate accountability.
INQUEST’s policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.
Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.
Death In Custody Inquest Notice
Tony Herbert, James Herbert’s father.
INQUEST INTO DEATH OF JAMES HERBERT IN POLICE CUSTODY IN YEOVIL, SOMERSET BEGINS MONDAY 8 APRIL
10am Monday 8 April for 3 weeks
Before HM Coroner Tony Williams, Eastern Somerset District
Venue: Wells Town Hall, Somerset
The inquest into the death of 25 year old James Herbert, who died on 10 June 2010, will begin on Monday 8 April 2013. James was the only child of Barbara Montgomery and Tony Herbert and was living with his mother at the time of his death. He had suffered mental ill health for several years.
On 10June 2010 James was seen in public acting strangely. The police were called to Bath Road, Wells, Somerset at around 7pm. Several police officers and members of the public were involved in restraining him and placing him in the back of a police van. It was a hot day and James was wearing a winter coat.
Limb restraints were applied to his ankles, legs and wrists. He is said by the police to have been detained under section 136 of the Mental Health Act. He was transported over 27 miles away to Yeovil Police Station (a 40 to 45 minute journey). Upon arrival at the station James was carried face down on a blanket from the police van and placed in a cell in the custody suite. His clothes were removed and he was left naked on the floor before officers withdrew from his cell.
James was observed to be unmoving and unresponsive. CPR was commenced and an ambulance was called. James was transferred to A&E at Yeovil Hospital. After unsuccessful attempts to revive him, James was pronounced dead at 9.20pm.
The family hope the inquest will address the following questions and issues:
- § Whether Avon and Somerset police acted appropriately and proportionately in their response to someone they knew, or ought to have known, was mentally ill
- § Whether adequate attempts were made to avoid the use of force
- § Why members of the public were permitted to be involved in the restraint
- § Why he was driven 27 miles to Yeovil police station instead of being taken to the nearest place of safety that had medical support
- § Whether James was appropriately monitored throughout that journey
- § Why he was deemed fit for detention on arrival at the police station despite his condition and why all his clothing was removed
- § Whether there was a delay in calling for emergency medical assistance
- § Whether the emergency medical response was adequate
James’s parents said:
“On June 10th 2010, our son James, who was 25, died shortly after being detained by Avon and Somerset Police under section 136 of the Mental Health Act. James was a highly intelligent and compassionate person. He had mental health issues but at no time in his life had he ever been violent to others. For us, the loss in such circumstances of our only child was a terrible event, a deep and painful shock and it feels like a light in our lives has been extinguished.
“We hope and pray that at James’s inquest, the light of truth and justice will shine and the lessons learned will at least help the steps to be taken that will prevent other families from experiencing the same agony. James lost his future but our hope is that his tragic death may help others keep theirs.”
Deborah Coles, co-director of INQUEST said:
“This is another shocking death in police custody of a man suffering mental illness. James Herbert was a vulnerable man in need of care and protection who died in the most disturbing circumstances.
“INQUEST is working on too many similar cases raising near-identical questions and concerns about police treatment of vulnerable people with mental health issues. It is vital for the family and the public that there is a thorough and far-reaching inquest into James Herbert’s death, and that action is taken not just locally but at a national level to address what is a serious and ongoing failure to learn lessons.”
INQUEST has been working with the family of James Herbert since his death in 2010. The family is represented at the inquest/hearing by INQUEST Lawyers Group members Beth Handley from Hickman and Rose solicitors and barrister Alison Gerry of Doughty Street chambers.
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Notes to editors:
1. The IPCC’s published statistics on deaths in police custody for 2011/12 revealed that nearly half (7 out 15) of those who died in or following police custody were identified as having mental health problems.
2. Under Section 136 of the Mental Health Act the police may detain someone they believe is suffering from a mental illness and in need of immediate treatment or care. Section 136 gives authority for the police to take a person from a public place to a “Place of Safety”, either for their own protection or for the protection of others, so that their immediate needs can be properly assessed.
For further information, please contact: Hannah Ward, Communications Manager at INQUEST on 07972 492 230. Please use this number as the office is currently closed. Alternatively, please email hannahward@inquest.org.uk
INQUEST provides a general telephone advice, support and information service to any bereaved person facing an inquest and a free, in-depth complex casework service on deaths in custody/state detention or involving state agents and works on other cases that also engage article 2 of the ECHR and/or raise wider issues of state and corporate accountability. INQUEST’s policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths occurring.
Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.
HMP Wandsworth and London Ambulance Service severely criticised by jury at inquest concerning death of man imprisoned for stealing a gingerbread man during the London riots
Prison van arrives at Wandsworth Prison
A jury has severely criticised HMP Wandsworth and the London Ambulance Service (LAS) for ‘failures within the systems and the consequent delays’ which meant not enough was done to attempt to save the life of a man detained during the 2011 Croydon riots for stealing from a bakery.
James Best, 37, was being held on remand at HMP Wandsworth when he collapsed and died of a heart attack after a gym session on 8 September 2011. At the conclusion of an inquest into his death on Friday, the coroner recorded a narrative verdict describing the shambolic response once James became ill. The jury described the timing of the call to the LAS, and the lack of priority given to the call by the LAS, as both ‘potentially contributing to’ James Best’s death.
James had a history of mental ill health and medical problems including Crohn’s disease and asthma. In accordance with prison service policy he should not have been allowed to use the gym without the approval of healthcare staff. The inquest heard evidence that the gym assessment policy had broken down, with assessment forms being signed by prisoners rather than officers and no referrals being made to healthcare
Evidence at the inquest raised serious concerns over the efficacy of the response of healthcare staff to James Best’s needs following the heart attack. In addition there were lengthy delays with the dispatch of an emergency ambulance. The call from the prison to the London Ambulance Service lasted 13 minutes despite an officer telling the LAS that James was having difficulty breathing and repeated requests for an ambulance by the nurse attending to James. James was declared dead as the paramedics arrived.
James had been convicted for stealing from a looted bakery. He was remanded in custody awaiting sentence. This was his first time in prison. At the time, magistrates were issued with advice from the courts and tribunals service to disregard normal sentencing guidelines for offences committed as part of the 2011 riots. Consequently there was a surge in the prison population, putting increased pressure on already crowded prisons.
James Best’s foster mother Dolly Daniel, who looked after him from the age of 15, said:
“He was such a loving person and our other children looked up to him as a hero. He was always looking out for friends and we just can’t believe he has gone.
“To find out that his death may have been avoided if there were proper checks on his health is so hard to take in.
“He was let down by the justice system – he should never have been in prison in the first place – and they basically ignored his health issues. I just hope that the procedures can be improved so that no one else has to suffer as we have.”
Deborah Coles, co-director of INQUEST said:
“Not only should James never have been imprisoned in the first place but there remain serious questions about why a prison like Wandsworth that has seen a disturbing number of deaths is still failing to implement basic policies and procedures designed to protect the health and safety of its detainees.
“The Prison Service needs to urgently review and act on the serious systemic failings exposed by this inquest. Whilst sentencing policy remains outside the scope of the inquest serious questions must be asked of Government as to the decision to imprison a vulnerable man for such a trivial offence. ”
Nancy Collins, representing James Best’s family, said:
“The circumstances of James’ tragic death are symptomatic of a prison service in crisis. The evidence heard at the inquest shows that James was failed by the prison staff, the prison healthcare staff and the London Ambulance Service.
“Unless urgent measures are implemented to address those failures there is a very real risk that there will be other avoidable deaths in prison custody.”
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Notes to editors:
1. In 2011 inspectors at HMP Wandsworth reported that the prison, which holds over 1,500 prisoners, was branded the most “unsafe” in the country for prisoners. There were 11 deaths at the jail between January 2010 and June 2011, and last week’s inquest was the third this year.
2. For further information, please contact Hannah Ward, Communications Manager at INQUEST on 020 7263 1111 | 07972 492 230 | hannahward@inquest.org.uk
INQUEST provides a general telephone advice, support and information service to any bereaved person facing an inquest and a free, in-depth complex casework service on deaths in custody/state detention or involving state agents and works on other cases that also engage article 2 of the ECHR and/or raise wider issues of state and corporate accountability. INQUEST’s policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths occurring.
Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.
“Lady in the Lake” Killer Inquests Starts
An inquest is due to start into the death of “Lady in the Lake” killer Gordon Park, who was found dead in his prison cell in Lancashire more than three years ago.
Park escaped justice for nearly 30 years after he murdered his wife Carol and dumped her body in Coniston Water in the Lake District.
He was found unconscious in his cell at HMP Garth in Leyland on January 25, 2010 on his 66th birthday.
Staff and paramedics attended but he was pronounced dead less than two hours later.
An investigation by the Prisons and Probation Ombudsman was launched.
The retired schoolmaster bludgeoned his wife to death with an ice axe in July 1976 and dumped her in the lake near the family home in Leece, near Barrow-in-Furness.
He claimed he had taken their children on a trip to Blackpool on the day she vanished to live with another man when she was 30.
Her body came to rest on an underwater ledge and was found by amateur divers 21 years later.
She was found wearing her blue baby doll night-dress, arms bound tightly and with tape over her eyes.
Park was arrested and charged with her murder but the case against him was dropped in January 1998 when the Crown Prosecution Service said it did not have enough evidence.
A second police investigation uncovered fresh evidence by linking him to the knots used to tie up the body and a piece of Westmorland green slate used to weigh it down that matched the stone used to build the family home.
The 2005 guilty verdict at Manchester Crown Court brought an end to one of Britain’s most notorious unsolved murders.
Park was jailed for life to serve a minimum of 15 years.
In November 2008, the Court of Appeal rejected an application by Park for leave to appeal against his conviction by calling fresh expert testimony on the geological evidence at his trial.
His supporters have been battling to refer the case to the Criminal Cases Review Commission, which investigates possible miscarriages of justice.
The inquest at Preston Coroner’s Court is scheduled to last four days and will be heard before a jury.
LITVINENKO FILES TO STAY SECRET
Sensitive evidence allegedly exposing the MI6 ties of spy Alexander Litvinenko, assassinated by poison in London, will be examined in secret, a coroner ruled.
Lawyers for the former KGB agent’s family believe the files may contain the key to his assassination in November 2006.
His widow Marina spoke of her disappointment that such material was still being shrouded in secrecy amid claims the Government planned to “suppress” evidence to protect relations with Russia.
Mr Litvinenko, 43, was poisoned with polonium-210 while drinking tea at the Millennium Hotel in Grosvenor Square.
His family believes he was working for MI6 at the time and was killed on the orders of the Kremlin.
They have urged the Government to reveal documents which they believe would support this theory but Foreign Secretary William Hague argued the disclosure of certain files relating to the case could risk national security.
Coroner Sir Robert Owen told a pre-inquest review at London’s Royal Courts of Justice he would consider a selection of that evidence in private, giving Mr Hague’s application the “most stringent and critical examination”.
The nature of the evidence contained with files remains unclear but lawyers for the Litvinenko family claim the documents could point towards Russian state involvement.
The hearing was adjourned ahead of a directions hearing on March 14.
The coroner gave no indication on when he would conduct the private hearing but told the pre-inquest review he could reconvene proceedings relating to the files in public if he deemed it possible to do so.
ARMED ROBBER DIED WHEN ‘HELD FACE DOWN’
An armed raider who tried to rob a bookies died after he was disarmed and restrained by members of the public, an inquest has been told.
Alan Levers, 50, from Plymouth, was wearing a gas mask when he went into the Ladbrokes branch on Crownhill Road in the Devon city shortly before 7pm last Friday.
An inquest into his death was opened this afternoon, at which it was heard a post-mortem examination had yet to establish a cause of death.
Speaking at the hearing, police inspector Steve Brownlow said the unemployed man was carrying an imitation pistol as he attempted to raid the shop.
He added: “He (Levers) was restrained and disarmed by three members of the public.
“He was held face down on the floor.”
He said police officers later handcuffed and arrested Levers while he was on the floor, but noticed he was not moving.
“They (police) removed the mask and commenced CPR,” Mr Brownlow said.
“Paramedics attended but he was pronounced dead at the scene.”
The time of death was confirmed at 7.37pm and Levers’ body was identified the following day by his girlfriend.
Coroner Ian Arrow adjourned the hearing for a later date.
Police praised “brave” members of the public after the incident, saying those who restrained Levers would not have known if the gun was a fake.
The incident had been voluntarily referred to the police watchdog, the Independent Police Complaints Commission, as officers from Devon and Cornwall Police had arrested Levers at the scene before his death was confirmed.
But a statement on the force website later read: “The IPCC has contacted Devon and Cornwall Police to say that having made an assessment, this matter should be subject to a local investigation.”
A police spokesman confirmed this ended the IPCC’s involvement, and that Devon and Cornwall Police’s investigation into the circumstances of the incident would continue as normal.
Levers’ family later apologised for the armed raider’s actions.
