Hearing Finds Insufficient Care Was Provided At Bristol Prison

A coroner has called on the government to take action to prevent future prisoner deaths following the death of a man on remand at HMP Bristol.

Shaun Dewey, 30, was found dead in his cell on 13 April, 2018. He had taken his life, an inquest was told.

That January he had been moved from another jail for his own safety, after being attacked by inmates. 

However, suicide and self-harm prevention procedures called Assessment, Care in Custody and Teamwork (ACCT) - which had been in place - were withdrawn by HMP Bristol staff in February 2018.

Following the death of Shaun, from Worcestershire, his family instructed specialist lawyers at Irwin Mitchell to investigate if more could have been done to help him. 

Shaun’s family are now calling for lessons to be learned to prevent future deaths in custody. It comes after an inquest found there was a “failure” by HMP Bristol to “act sufficiently” to safeguard Shaun during his struggle with anxiety, depression and separation from his family.

The senior coroner for Avon, Maria Voisin, confirmed she will issue a Prevention of Future Deaths report, calling on the government to consider the higher risk of suicide among prisoners on remand, who are held in prison alongside convicted prisoners while awaiting their trial, and whether national guidance needs to be changed to reflect this.

Expert Opinion

“Shaun’s family have had significant concerns about his death and while nothing can make up for what has happened we are pleased that the inquest has thoroughly investigated the circumstances leading up to his death.

It is clear that the ACCT self-harm and suicide monitoring for Shaun should not have been closed in February 2018, and the jury also found that there were sufficient signs to warrant the opening of another ACCT before his death.

It is now vital that HMP Bristol and the Prison Service ensure lessons are learned so that the issues seen in this case are not repeated in the future.”
Oliver Carter - Associate Solicitor

Shaun's family said after the inquest: “We have waited more than a year for answers about what led to Shaun’s death and this inquest has been an incredibly difficult time for the entire family. Shaun was a much loved fiancé, father, son and brother, and we all miss him terribly.

“Shaun had never been in prison before and was struggling to manage his depression and anxiety, as well as fearing for his own safety and that of his family. We were just trying to get him through to his trial, where he would have argued that he acted in defence of himself and his family. Tragically, he could not hold on that long, and saw taking his own life as his only option.

"Prisons have a duty of care in relation to the safety of those under their supervision and we were shocked to see the range of issues which Shaun faced.  All we can hope now is that lessons are learned and no other family has to go through what we have.”

A spokesperson from the charity INQUEST said: “Prisons are harmful environments and distress is further heightened for those with experiences of mental ill-health. There were clear warning signs about Shaun's deteriorating mental health, yet the prison neglected him when he was most in need of care. The dangerous practices exposed at the inquest must be acted on to prevent future deaths.”

Background

Shaun was remanded in HMP Hewell in Worcestershire, in September 2017, awaiting trial charged with murder.

However, in January 2018 he was moved to HMP Bristol for his own safety after being attacked by other prisoners. 

Following the attack on him at HMP Hewell, Shaun self-harmed and was put on suicide and self-harm prevention procedures called Assessment, Care in Custody and Teamwork (ACCT).  The monitoring commenced again after his transfer to HMP Bristol in January last year, but ended on 12 February. The inquest jury heard that the ACCT should not have been closed, as the required actions on Shaun's 'care map' had not all been completed.

A three-week inquest into Shaun’s death concluded this week. It found that although there were prison, healthcare and mental health systems in place to safeguard Shaun, they were "insufficiently applied to prevent his death” and when signs of concern were identified, "there was failure to act sufficiently and there was a tendency to close actions before issues were fully resolved.”

An inquest jury returned a narrative conclusion that Shaun died as a result of suicide related to “uncoordinated supervision” and a failure by the prison to “act sufficiently” to safeguard him during his struggle with anxiety, depression and separation from his family.

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