Key Takeaways
- The inquest into the death of a prisoner, Crosher, found that there were several missed opportunities to prevent his death.
- Crosher had a history of vulnerabilities and had previously attempted to take his own life.
- Prison staff were unaware of important information about Crosher’s vulnerabilities and did not take adequate action to support him.
- There were discrepancies in the recording of observations and a gross failure to escalate Crosher’s case when he rang his cell bell.
- The inquest found that two officers failed to respond when they found Crosher’s cell observation hatch was covered, leading to a delay in calling a code blue.
Introduction to the Case
The inquest into the death of a prisoner, Crosher, has shed light on the circumstances surrounding his tragic demise. The court heard that Crosher was transferred to Lowdham Grange prison on July 19, 2023, after being recalled to prison earlier that year. At the time of his arrival, his paperwork included a section that described him as having vulnerabilities and posing a medium risk of harm towards himself through the continued misuse of illicit drugs. This information was crucial in understanding Crosher’s needs and providing him with the necessary support. However, the jury found that safer custody staff at the prison were unaware of this information, despite Crosher being described as "seeming a little vulnerable" by healthcare staff during his screening.
Initial Incidents and Lack of Support
In the months following his arrival, Crosher was involved in several incidents that raised concerns about his well-being. He was assaulted in August and September, but there was no welfare check or follow-up action taken by prison staff. Furthermore, when he was found under the influence of drugs, he was not checked on to an adequate standard. These incidents should have triggered a response from prison staff, but instead, they were met with inaction. The lack of support and follow-up action created an environment in which Crosher’s vulnerabilities were not addressed, putting him at greater risk of harm.
Missed Opportunities and Inadequate Response
On October 7, Crosher pressed his cell bell to inform staff that he had feelings of self-harm and was "under threat on the wing". This was a clear indication that he needed support and attention. However, the jury found that there was a "missed opportunity" to prevent self-harm, and despite being placed under the assessment, care in custody and teamwork (ACCT) process, Crosher was "left unattended, breaking from policy". This failure to respond adequately to Crosher’s needs was a critical mistake that had severe consequences. The fact that he was treated by healthcare staff after self-harming, but only moved from his cell after starting a fire the following morning, highlights the inadequacy of the response.
Inadequate Observation and Response
The inquest also found that there were discrepancies between the recording of ACCT observations in the documentation and the observations actually undertaken by night staff on October 11. This lack of accuracy and attention to detail meant that Crosher’s case was not escalated when it should have been. When he rang his cell bell at 02:30 GMT, there was a gross failure to respond, and two officers failed to react when they found his cell observation hatch was covered. This delay led to a code blue being called at 07:06, but by then, it was too late. Despite medical attention, Crosher was pronounced deceased outside his cell at 07:48.
Conclusion and Reflection
The inquest’s findings are a stark reminder of the importance of providing adequate support and care to vulnerable prisoners. The series of missed opportunities and inadequate responses that led to Crosher’s death are a tragedy that could have been prevented. The fact that prison staff were unaware of crucial information about Crosher’s vulnerabilities and failed to take action when he needed it most is a serious concern. The discrepancies in observation records and the failure to escalate his case when necessary are also alarming. The inquest’s findings highlight the need for prisons to prioritize the well-being and safety of prisoners, particularly those who are vulnerable or at risk of harm. By learning from this tragedy, prisons can take steps to prevent similar incidents from occurring in the future and ensure that prisoners receive the support and care they need.
