Inquest Finds Neglect Caused The Death Of Man At Guys Marsh Prison In Dorset
Family Calls For Change After Vulnerable Man With A History of Self-Harm Was Left Unobserved for Hours After Being Found Collapsed
The family of a man found dead in his cell at HMP Guys Marsh is calling for improvements in the treatment of mentally ill prisoners, after an inquest heard of serious failings in the run up to his death.
Anthony Clacher, 36 was found hanged in his cell on 21 March, 2018, just six days after being transferred to the prison which had been in special measures since January 2017 after Inspectors found "failings in almost every area of the prison we looked at".
Earlier on the day of his death, staff found Anthony collapsed at the bottom of a flight of metal stairs apparently under the influence of the drug spice. Medical staff from the private healthcare provider Practice Plus Group, (formerly Care UK), didn't dispute the decision from prison officers that Anthony was fit to be returned to his cell, the hearing heard.
He was then left unobserved for several hours, despite having been taken off a self-harm and suicide prevention plan only three days before. When his cell was unlocked an officer failed to carry out a mandatory welfare check. The court heard that Anthony was only found sometime later when an officer happened to deliver post to his cell.
The jury at the three week inquest at Bournemouth Town Hall heard that a healthcare assistant had described the drug problem in the prison as "horrific" around the time of Anthony's death. Another witness described a practice of 'guinea pigging' where new strains of spice were tested out on vulnerable prisoners by dealers.
Anthony, described by his family as "a much loved brother, son and uncle" was serving a two year sentence for theft connected to his drug dependency. The court was told he suffered with post traumatic stress disorder following childhood sexual abuse whilst in care. He heard the voice of his abuser, for which he had been prescribed anti-psychotics in the community.
He asked for this medication to be restarted when he entered HMP Bullingdon in Oxfordshire in October 2017. However, the court heard that no mental health assessment had been done and no anti-psychotic medication was prescribed despite Anthony still reporting distressing voices when he arrived at HMP Guys Marsh five months later after a brief period in HMP Winchester.
After his first act of self-harm in HMP Bullingdon Anthony was placed on the prison service's self-harm and suicide prevention programme, known as 'ACCT' which is supposed to identify and address the source of a prisoner's distress as well as putting in place a regime of monitoring to keep them safe.
The court heard that one of the key items on Anthony's ACCT care plan was for him to see a mental health worker for access to medication. On 19 March, 2018, Anthony's ACCT was closed despite him still not having had a mental health assessment or being given the medication he had received in the community, the inquest was told.
Various prisoners told the inquest that Anthony was being bullied in the days leading up to his death, and that some prisoners were heard telling him to kill himself. One witness said he saw other prisoners place a noose around Anthony's neck the day before his death. Another said that Anthony was being "terrorised" on the prison's Dorset Wing.
A report submitted to the coroner by Dorset Police concluded that Anthony "was living in a culture where prisoners were free to bully him right up to the time of his tragic death."
The court also heard that Anthony's mother had received threatening phone calls when he was in HMP Bullingdon from individuals demanding that she transfer money into various bank accounts.
Anthony's death was the first of four at Guys Marsh between March and June 2018, in which spice played some part.
The jury in the inquest heard at Bournemouth Town Hall from 29 September to 19 October before senior coroner Rachael Griffin, concluded that the death was caused by a "gross failure to provide basic medical attention or [to] observe Anthony" after being returned to his cell on 21 March 2018. They found there was insufficient evidence to indicate that Anthony was capable of forming the necessary intent to take his own life, and therefore his death was not a suicide. The jury also found insufficient evidence to conclude misadventure. Mrs Griffin told the court that she would be writing to the prisons minister, Victoria Atkins, raising her concerns that further deaths could occur if action is not taken on a national level.
Following Anthony's death, HMP Guys Marsh introduced a new policy requiring officers to monitor all prisoners found under the influence of spice – described by staff as known to increase risk of suicide - regularly until the following day, to ensure their safety.
Anthony's sister, Christine Clacher, said after the inquest: "Despite his struggles with mental illness and drug addiction Anthony was the loveliest guy. When he was in prison he gave one of his friends some of the little money he had as he didn't want them to be sleeping rough when they got out.
"Anthony was so close to our mum and was really looking forward to seeing her once he got out. If it wasn't for the toxic environment in Guys Marsh and the shocking failings to help him over many months, then I know that he would still be here. He would never have wanted to hurt our mum, he just loved her too much. Mum died shortly after Anthony, totally heartbroken.
"He was a human being who had been through some terrible experiences and deserved to be treated with care and respect. As a family we call on the Government to make urgent changes to ensure prisoners in similar situations get the treatment and support they need."
"The law says that prisoners are entitled to the same standard of healthcare as they would receive in the community. It is shocking that someone with Anthony's complex needs did not receive the same medication he had been given by his community GP.
"When, as appears likely, Anthony turned to illicit drugs as a form of self-medication and was found collapsed on the floor hallucinating, he was failed again when officers left him unobserved in his cell for hours. They even took away his TV as a punishment for being under the influence, despite his case notes saying TV was an important distraction from the voice in his head.
"At this stage, we always call for lessons to be learned in these cases, but while we continue to send people with serious mental illnesses into a prison system that seems to be in a crisis of its own and unable to improve, then more families will be mourning the death of their loved ones." Gus Silverman - Associate Solicitor
Selen Cavcav, a caseworker at the charity INQUEST said: "Prisons are ill-equipped to keep people with serious mental ill health safe. Anthony was in the care of the state and deserved a basic duty of care. Instead he was failed by many of the individuals and agencies who should have looked after him. How many more avoidable deaths, inquest findings and inspection reports are needed for this government to address serious failures in our prisons in a meaningful and effective way?"
Further failings found by the jury
The jury also identified the following inadequacies or omissions as possibly contributing to Anthony's death:
Anthony was "[n]ot seen by anyone from the Mental Health Team in a timely fashion whilst at Guys Marsh"
There was a "lack of ACCT training for all prison officers" despite this having been a specific recommendation made by the Prison and Probation Ombudsman following the death of another prisoner in HMP Guys Marsh in 2016
The "ACCT should not have been closed without mental health assessment"
There was no "24/7 mental health care" at HMP Guys Marsh, combined with a "lack of mental health staff / resources"
"Records [were] not following prisoners adequately between prisons"
"Inadequate record keeping and not following procedure properly during welfare checks and unlocking"
Government delays in publishing a national prison drugs strategy
In its May 2019 report into Anthony's death the Prison and Probation Ombudsman (PPO) stated: "In a number of recent investigations, we recommended that the Chief Executive of HM Prisons and Probation Service (HMPPS) should issue detailed national guidance on measures to reduce the supply and demand of drugs, including PS in prisons. The acting Ombudsman also wrote to the Prisons Minister raising her concerns about the high number of deaths she was investigating that were due, or linked, to the use of PS, the Chief Executive told us that HMPPS plan to issue a national drugs strategy in the autumn of 2018. We are concerned that at the time of writing (February 2019), this strategy has still not been issued. We therefore make the following recommendation:
"The Chief Executive of HMPPS should provide the ombudsman with a revised date for issuing national guidance on measures to reduce the supply and demand of drugs in prison, and an assurance that this new date will be met".
In a statement provided to the inquest a senior civil servant within the Ministry of Justice said that work had begun on a national drugs strategy in the "spring of 2018" but that publication had been delayed "for a number of reasons, including the decision to add a sizeable guidance document, an underestimation of the size of that task, and delays with ministerial clearance and securing a No. 10 Grid Slot for publication."
A national drug strategy for prisons was eventually published in April 2019, despite the PPO having raised concerns in July 2015 about a growing number of deaths in prison linked to new psychoactive substances such as Spice.
Recommendations following a previous death at Guys Marsh
In November 2016 the PPO issued a report into the death of another prisoner at HMP Guys Marsh, Simon Lane, in March 2016. The PPO recommended: "The Governor should ensure that there is an effective supply reduction strategy to help eradicate the availability of new psychoactive substances, and that staff are vigilant for signs of its use and are briefed about how to respond when a prisoner appears to be under the influence of such substances."
Despite this recommendation no system for monitoring prisoners found under the influence of new psychoactive substances, such as spice, was put in place until after Anthony's death.
Prison inspectorate findings
In January 2017 HM Inspectorate of Prisons published its report following an announced inspection of HMP Guys Marsh in December 2016, the last inspection before Anthony's death.
The report stated: "Our findings at this inspection … were very disappointing. Less than one third of our previous recommendations had been achieved. … Far too little had been done far too late to address the serious concerns we raised in our previous report. It was striking how few of our recommendations had been addressed and in some respects the prison had got worse. …
Some 74% of prisoners told us they thought illegal drugs were easily available and nearly a quarter indicated that they had acquired a drug problem at the prison.
This inspection found failings in almost every area of the prison we looked at
Spice use was widespread and particularly problematic. Not enough was being done to reduce drugs supply and make the prison safer.
The prison was not monitoring the full extent of the [spice use problem] problem and was not doing enough to reduce availability.
In our survey, over a quarter of prisoners said that they currently felt unsafe, which was far more than at similar prisons. Over half said that they had felt unsafe at the prison at some time, which, again, was far worse than at similar prisons and than at the time of the previous inspection.
Levels of violence had risen year on year since the previous inspection, with the main causes being drugs and debt. …
In spite of these levels of violence, too little had been done to make the prison safer."
In March 2019 HM Inspectorate of Prisons published a further report following an announced inspection of HMP Guys Marsh in December 2018 and January 2019. The report found a number of improvements in the prison but noted: "… there had been many incident, and sadly some deaths, relating to use of illicit drugs, and to the issues of debt and intimidation arising from the trade in those drugs. A wide range of security measures had been taken to cut the supply of drugs, but more work was needed in light of continuing poor outcomes. In particular, the response to the drugs problem was undermined by the fact that intelligence was not always processed promptly or analysed systematically to identify trends and patterns, and target searching was often not taking place.
… the spread of [drug] testing across each month was too predictable and, despite all the efforts, evidence showed that illicit drugs were still far too easily available in the prison…"
Gus Silverman
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Spencer Bailey
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