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Jury Identifies Failings in Risk Management Following Self-inflicted Death of First time Prisoner
A jury has returned a critical narrative conclusion following the inquest into the death of Lloyd Joseph Skelton, 21 who died at Leicester Royal Infirmary on 1 September 2014 after being found hanging in his cell on the segregation wing at HMP Leicester on 29 August 2014. The inquest was held at Leicester Town Hall from 1-10 March 2016.
Lloyd was a talented young man with aspirations of a career in the music industry, however he had a long history of mental health issues. On 30 July 2014, following three incidents which occurred over a number of days Lloyd was remanded to HMP Leicester, this was his first time in prison (and in fact first time that he had really been in trouble with the police). A mental health assessment had been carried out at Court, but it was decided that Lloyd was unsuitable for admission to a psychiatric inpatient unit.
Lloyd was placed on an ACCT following concerns raised by the nurse in reception. The following day, Lloyd headbutted a prison officer, and was moved to the segregation unit, where he remained for over four weeks until his tragic death.
Issues were raised on behalf of the family as to whether the segregation unit was the most appropriate place for Lloyd considering his deteriorating mental health, however the jury concluded that it was the most appropriate location available to cater for Lloyd’s needs and to protect the safety of Lloyd and others. It is however interesting to note that this same unit was declared “unfit for habitation” and was recommended to be closed immediately by HM Inspectorate of Prisons in a report released earlier this year.
Lloyd was placed on a three-officer unlock throughout his time in segregation, which the jury concluded was inappropriate, as a review on 22 August had declared he was of “low risk”. On 29 August, the three-man unlock had delayed Lloyd being given his evening meal, approximately an hour before he was found hanging. This was due to a shortage of staff.
On 29 August, Lloyd was reviewed by his case manager and a mental health nurse as part of the ACCT procedure, with two officers also in attendance. Lloyd did not engage with the review but despite this the case manager decided to close the ACCT. Her reasoning for this was that in segregation prisoners would still be observed on an hourly basis so they could still monitor him, however these checks are not mandatory. The jury concluded that it was an error to close the ACCT at that stage, and that this was a contributory factor in his death, as the ACCT checks were mandatory, and it stipulated that staff must have three meaningful conversations per day with Lloyd.
The hourly checks on the unit were to be recorded in the observation log, and although observations were recorded in the unit’s log book, the CCTV from the unit’s landing, showed that in fact the checks at 13:30, 14:30 and 17:30 were notcompleted. It also transpired that the 17:30 check was not noted in the log when police initially attended and took a photocopy the day after Lloyd was found, yet when an officer returned the following week to retrieve the original, it had been added but without a signature. The jury concluded that the failure to conduct these observations contributed to his death.
Lloyd’s family said:
“Lloyd was an intelligent, talented and sensitive young man with so much to offer and an ability to inspire those around him. Our family are distraught over his tragic death at such a young age, before he had the chance to fulfil his vast potential.
Although we are pleased with the conclusions of the jury and the criticisms they have made, this is a small consolation. It was clear Lloyd was crying out for help, but the prison’s response was to lock him away on the segregation unit, which is difficult to accept.
We would like to thank our legal team – Gemma Vine, Ifeanyi Odogwu and Charles Myers – for all the hard work they have put in to Lloyd’s case”
Gemma Vine, solicitor representing Hannah’s family said:
“This is a tragic case of a talented, yet troubled young man with significant mental health issues, who clearly should not have been in prison in the first place. This case highlights both failings with HMP Leicester and also a national problem regarding a lack of resources to support prisoners with serious mental health disorders. Considering the high number of prisoners who are deemed to be affected by Mental Health Lloyd’s death serves as a reminder that the Ministry of Justice needs to conduct an urgent overhaul of the prison system.”
The family is represented by INQUEST Lawyers Group members Gemma Vine from Lester Morrill solicitors and Ifeanyi Odogwu, Garden Court Chambers.