Prison faces scrutiny after three suicides in 19 days. Coroner cites poor investigation transparency and unsafe conditions.
The coroner, Laurinda Bower, called out prison bosses and the Ministry of Justice (MoJ). She noted a lack of transparency in the investigation and found inconsistencies in testimonies and written reports. The MoJ was even fined for not sharing key evidence.
The coroner believes further deaths will occur without change, prioritizing prison learning. Data indicates that 40% of prisoners lacked healthcare before suicide in UK prisons between 2020 and 2023.
Andy Slaughter stated the system fails prisoners, and Charlie Taylor warned more deaths are possible without action. Anthony Binfield, 30, died on March 6, 2023, after requesting mental health staff a week prior.
The prison’s email to mental health staff went to Sodexo instead of Serco, the previous operator. While monitored every half hour on his death day, CCTV revealed these checks did not happen, and staff delayed entering his cell. Officers used pens to move paper in the observation panel.
An expert suggested prompt entry could have saved him. A note revealed Binfield felt unheard, let down, and had no one to turn to for help. David Richards died a week later after being recently moved from another prison.
His vulnerability was not considered during the transfer, and he expressed feeling unsafe. Richards, formerly the Dreamboys’ leader, was jailed for attempting to murder his wife. Richards also didn’t take his medication for days, allowed to take it unsupervised.
Rolandas Karbauskas, a Lithuanian, died by suicide on March 25, five days after arriving at the prison. Speaking no English, he stated he felt depressed, but no plan addressed his isolation.
The coroner warned about future self-inflicted deaths related to language barriers and isolation. Binfield and Karbauskas’ deaths were ruled suicides, while Richards’ death was ruled an accident. The coroner sent a report to the prisons minister, Sodexo, Serco, and the local NHS Trust.
The coroner highlighted recruitment issues, training problems, and staff feeling overwhelmed and unsupported. She criticized the failure to share information between prison and healthcare, calling the prison transfer system unsafe, and noting repeated failure to learn.
The Ministry of Justice took over the prison in December 2023 to improve safety and security. Sodexo regrets the deaths of the three men and apologized to the families, committing to consider learnings but no longer managing the prison.
The Ministry of Justice offered their apologies, acknowledging failures occurred in these cases. They claim to have boosted staffing levels, reopened education opportunities, and partnered with police to stop contraband.