A prisoner who died at HMP Nottingham had a history of self-harm and had already attempted to take his own life in police custody, an inquest has heard.
Shane Stroughton, who was the first of five inmates to die at the jail in the space of a month, was found hanged in his cell in September 2017 despite having “frequent” contact with medical professionals.
The 29-year-old, who was originally jailed for assault at the age of 19, was recalled to prison for breaching a curfew after being released on licence three months before his death.
An inquest jury at Nottingham Coroner’s Court heard that an ambulance was called to the jail and CPR was administered but Mr Stroughton could not be resuscitated.
The category B prison, which has a capacity of 1,060, was found to be “fundamentally unsafe” following an inspection in January last year – prompting the first use of the “urgent notification” system.
Introducing the case to the jury, Assistant Coroner Ivan Cartwright said: “At prison, he was accommodated in a number of different cells.
“During his time in prison, Mr Stroughton had frequent contact with healthcare and medical staff.”
Mr Cartwright told the jury that the inmate had a history of self-harm.
He said: “Mr Stroughton made an attempt to hang himself in police custody.
“He made a number of different attempts to harm himself.
“On September 13 2017, a prison officer was unlocking cell doors for prisoners to collect their evening meals. They found Mr Stroughton hanging.”
The inquest, expected to last seven days, continues.
The Prisons and Probation Ombudsman, who investigates deaths and complaints in prisons, echoed the findings of the Chief Inspector of Prisons’ report of an inspection at HMP Nottingham.
The Acting PPO, Elizabeth Moody, said: “It is highly troubling that HMP Nottingham has a history of failing to implement recommendations from our investigations into deaths at the prison”.
The PPO makes recommendations following investigations into deaths in prisons so that the prison service can learn from mistakes and prevent them being made in the future. Final PPO reports on deaths investigations are not published until the end of inquests but important findings and recommendations that could lead to greater safety in a prison are shared with the prison and HM Prison and Probation Service (HMPPS) as they emerge.
Elizabeth Moody added: “It is a matter of great concern that we found some similarities, not only between the deaths of the five prisoners who took their own lives last autumn, but also with deaths which happened earlier in the year and before. The Chief Inspector is right to highlight the apparent inability of the prison to learn lessons and I agree that until it can demonstrate progress in this critical area the risk of future deaths will remain high.”
She also said: “Complaints from prisoners frequently indicate poor custodial care. I am troubled that my office upheld proportionately more complaints from prisoners at HMP Nottingham, than in other similar prisons. This is consistent with the findings of the Chief Inspector and should be a source of concern to the management of HMPPS.”
The Chief Inspector, Peter Clarke, wrote publicly to David Gauke on 18 January, invoking a new procedure to demand urgent action on HMP Nottingham from the Justice Secretary. He raised concerns over eight apparent self-inflicted deaths at HMP Nottingham in the two years up to January 2018, as well as high levels of self-harm.
At the same time, Elizabeth Moody raised key concerns with the Ministry of Justice which had been identified in her investigations into recent deaths at the prison:
The importance of initial identification in prisoners of risk of suicide or self-harm.
Assessment and management of those individuals, particularly applying multi-disciplinary assessment rather than relying on the way the prisoner presents and talks on arrival in the jail.
Referring mental health concerns and issues to healthcare or other experts.
The importance of staff responding, in line with HMIP expectations, when prisoners press their cell call bells and of staff entering cells promptly when prisoners are found unresponsive.
Keeping proper medical records.
Effective emergency response.
Elizabeth Moody said: “HMPPS is preparing an Action Plan to address the urgent concerns raised by the Chief Inspector, particularly in relation to suicide and self-harm at HMP Nottingham. It is vital that, this time, HMPSS fully incorporates PPO recommendations into the Action Plan. That will help HMP Nottingham create a new culture of safety and protection for vulnerable prisoners. Put simply, it will help save lives and prevent a repetition of the tragedies we saw in 2017.”
There was still too much serious violence and disorder at HMP Nottingham despite staff working hard to address this, said Peter Clarke, Chief Inspector of Prisons. Today he published the report of an announced inspection of the local prison.
HMP Nottingham holds just over 1,000 adult and young adult male prisoners. It was constructed in the 19th century but largely rebuilt between 2008 and 2010. It holds a range of prisoners, including those remanded by the courts, newly sentenced prisoners and prisoners nearing release. At its last inspection in 2014, inspectors were particularly concerned that levels of violence were far too high. This more recent inspection was announced in advance to give prison leaders time to focus on addressing these concerns. This inspection found that the prison still faced many significant challenges, but while much work still needed to be done, managers and staff were working very hard to address areas of concern. Progress had been made in all four healthy prison areas: safety, respect, purposeful activity and resettlement, although this was not sufficient in every case to change the assessments inspectors gave.
Inspectors were concerned to find that:
there was still too much serious violence and disorder despite real efforts made to address it;
high levels of force were used and, while governance of this had improved, some serious allegations about staff were not being taken seriously enough;
levels of vulnerability, in particular men with mental health problems, were higher than many similar prisons;
some men with complex combinations of vulnerability and problematic behaviour were being held in the segregation unit, which was inappropriate;
some wing-based staff remained distant and somewhat dismissive of the men in their care; and
offender management oversight arrangements needed to improve and some re-categorisation decisions were being wrongly made without appropriate risk assessments.
However, inspectors were pleased to find that:
some aspects of support for those arriving new into the prison had improved and induction was better, but delays in reception were still significant;
some excellent staff worked positively with prisoners and were not afraid to challenge or reward behaviour as appropriate;
the regime introduced in October 2015 was delivering a reasonable amount of time out of cell for most prisoners;
leadership of learning and skills had improved and attendance at activities was also better, but still needed improvement;
leadership in resettlement had improved and progress had been made from the previous very low base; and
reintegration work was developing well.
Peter Clarke said:
“We were far more optimistic than when we last inspected in 2014. The decline in standards had been arrested, the culture within the prison had improved, and there was a real sense that the leadership of the prison had a grip on what needed to be done. The plans in place to make the prison safer and more decent were credible. However, much of the very real progress that had been made was fragile and a great deal of work was still needed to consolidate the position.
“There is no doubt that this prison has suffered from a lack of continuity and consistency in its leadership. At the time of this inspection there had been five governors in the space of four years. The current governor has grasped some difficult issues and laid some good if inevitably fragile foundations. However, our understanding is that he too will shortly move to another prison. For the future, every effort should be made to stabilise the leadership of this challenging prison.”
Michael Spurr, Chief Executive of the National Offender Management Service, said:
“I am pleased that the inspectorate has noted the improvements that staff have worked on at the prison and that they continue to show progress in a number of key areas, but there is still more to be done to bring Nottingham up to the standard we expect.
“Following the last inspection we moved a Governor from outside the area into Nottingham with a clear remit to stabilise the prison and to drive the urgent improvements required. He has done his job exceptionally well. We have now appointed an experienced Governor who is committed to securing the long-term future of the prison. I am confident he will build on the progress made and provide the continuity and leadership required to make Nottingham a high performing, successful establishment.”