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Minton Morrill client, Mary-Ann Walters speaks to media amid publication of appalling suicide and self-harm in custody stats

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Last week, the Ministry of Justice published their annual statistics for 2016 in relation to instances of violence, self-harm and suicide in our prisons. It was revealed that in the past twelve months, an all-time high 119 people took their own lives in prison in England and Wales, which constitutes an increase of 32% from the previous year, and a 24% increase from the previous record of 96 in 2004.

The published statistics confirmed what had already been suspected and reported anecdotally - that the prison estate is in the midst of unprecedented levels of violence, bullying, debt and self-harm. Prisoner-on-prisoner assaults went up by 28%, self-harm by 23% and assaults on staff by an incredible 40% in a one-year period - although coincidence does not necessarily equal causation, the dramatic increases in these statistics begs the question of whether extensive cuts to funding and prison officer numbers has finally begun to bite.

Liberal Democrat leader, Tim Farron, and the Royal College of Psychiatrists have each pointed to funding cuts as being causative of the ongoing crisis, with a lack of resources causing many prisoners with significant mental health issues to go without the support that they desperately need.

Mary-Ann Walters son, Jake Foxall, first arrived at HMP Glen Parva on remand on 16 October 2015, having been transferred from HMP Bullingdon. Mr Foxall was 19 years old, it was his first time in prison and he arrived with a suicide and self-harm warning form. During his time at Bullingdon, Jake had been placed on the Prison Service suicide and self-harm prevention procedure, Assistance, Care in Custody, and Teamwork (“ACCT”), having self-harmed on five occasions, including being found on one occasion with a bed sheet tied around his neck.

Jake expressed concerns both before and after his transfer to Glen Parva, as he feared that he may be harmed by associates of his co-accused, who he believed were at Glen Parva. Despite Jake making his concerns known, no investigations were carried out and no steps were taken to reassure him.

Jake self-harmed with an increased frequency at Glen Parva.  In late October, his cell-mate told officers that he had swallowed a razor blade, and a week later Jake claimed he had drunk bleach in an attempt to poison himself. He repeatedly raised concerns about his fears at Glen Parva, telling officers on multiple occasions that he “didn’t want to be here” and “… [could not] cope in this Prison”.

It appears from his ACCT paperwork that the daily observations of Jake were poor.  There were limited occasions when officers recorded a “meaningful conversation” with Jake, despite the ACCT demanding at least three per day. Jake continued to raise concerns about bullying and intimidation with prison officers, doing so on at least three further documented occasions on 3 and 6 November, and although he was moved to a cell opposite the staff office for further protection, he remained on the same wing.

Unfortunately it appears the move did little to allay Jake’s fears, as he was found hanging in his cell just after 10pm on 7 November. Officers raised the alarm and an ambulance was called while they entered the cell. Although paramedics were able to restart his pulse, Jake tragically died in hospital on 12 November 2015, just four weeks shy of his 20th birthday.

An inquest was listed for five days from the 8th of September 2016, and took place before a jury. It was plain to see from the evidence that exploration of Jake’s risk of suicide in Glen Parva was inadequate, with many staff involved in his care unaware or ignorant of the documentary evidence of his risk.  As with many other cases of self-inflicted deaths in prison custody, prison officers repeatedly relied on Jake’s “presentation” rather than consideration of his static risk factors. It was also evident that there was an almost complete failure to follow up his concerns about bullying and being under threat from associates of his co-accused.

Particularly remarkable was the evidence of the main Governor of HMP Glen Parva, Alison Clarke, who accepted in evidence that she had inadequate resources to properly protect prisoners from a risk of suicide. The published statistics seem to lend credence to Governor Clarke’s sentiment.

The jury returned a highly-critical narrative conclusion, condemning the prison’s management of, and response to, Jake’s risk and noting that there were ‘systemic failures’ and ‘inadequate resources assigned’ to his care. Jake’s death was the tenth self-inflicted death at Glen Parva since 2010, and the prison has been subject to previous Reports to Prevent Future Deaths and recommendations from the Prisons and Probation Ombudsman, specifically in relation to the operation of the ACCT procedure.

Although the coroner was reassured by some of the improvements that appear to be taking place, it unfortunately came to light just before the inquest that there had been an eleventh self-inflicted death in August 2016.

Given the history of Reports to Prevent Future Deaths and PPO recommendations, the coroner also made the decision that the report will be sent directly to the Chief Executive of the National Offender Management Service (NOMS) and the Lord Chancellor and Secretary of State for Justice, the Rt Hon Elizabeth Truss MP.

This is another incredibly sad case of a vulnerable young man, whose risks and vulnerabilities were not properly addressed at Glen Parva. There were several missed opportunities and failures to investigate or respond to Jake’s concerns in the weeks running up to his death

Of particular concern were the deficiencies in operating the ACCT procedure, as this has been highlighted in multiple previous Regulation 28 Reports to HMP Glen Parva, and also by the Prisons and Probation Ombudsman. It was striking, although unfortunately not surprising given what we have heard in previous cases, to hear Governor Alison Clarke admit in evidence that she did not have sufficient resources to properly protect at-risk prisoners from a risk of suicide. It was hoped at the time that the coroner’s decision to escalate the matter to the Chief Executive of NOMS and the Secretary of State for Justice would shed further light on this issue nationally, and lead to reforms from the top down to protect the vulnerable young people in our prisons. The issue was at the forefront of last week’s media coverage, but the challenge must be to ensure that it does not simply become, as the cliché goes, tomorrow’s fish and chip paper. The recent announcements as to increases in funding and prison officer numbers are to be welcomed, but there is clearly much work to be done to improve the culture and systems in place to protect some of the most vulnerable members of our society.

Speaking to the Guardian, Mary-Ann Walters wondered  “How could they let a 19-year-old boy kill himself in prison? They are supposed to be looking after him. They took him away from me, from his friends, and they didn’t look after him and now he is gone.”. Mary-Ann added “I feel like I have lost my left arm, a piece of my heart. I am not a whole person like I was when he was alive. It is hard to describe.” She is now very active in campaigning via social media and her involvement with the charity, INQUEST, and said that she has learnt to “try and focus on the living. It is very hard … I struggle.”

Mary-Ann Walters was represented by Gemma Vine and Charles Myers of Minton Morrill, and barrister, Jude Bunting of Doughty Street Chambers throughout the inquest process. We also acted for the families of four other young men who have died at HMP Glen Parva since 2011. We have established a national reputation in inquest law, having acted in some of the most high-profile inquests in the country in recent years - most notably the inquest into the deaths of Christi and Bobby Shepherd (the Corfu case involving Thomas Cook).

We are not interested in the deceased’s background – our aim is to ensure that the Deceased and the bereaved family’s voice is heard throughout the inquest process and that the family are able to obtain the answers they need in relation to their loved one’s death.

During the process, we work closely with a number of organisations, including the Prison and Probation Ombudsman Service, the Independent Police Complaints Commission and NHS trusts. We also have close links with INQUEST, a leading UK charity supporting bereaved families at inquests. Legal Aid may also be available in exceptional circumstances, which we can help you apply for, should you be eligible.

To find out how our specialist inquest solicitors in Leeds, Yorkshire and the North of England can help you, please contact us on 0113 245 8549 or email