Paul Coley death: Coroner highlights HMP Hewell failings
A number of failings by prison and healthcare staff contributed to the suicide of a father-of-five in a Worcestershire jail, an inquest has found.
Paul Coley, 44, from Wolverhampton, was found dead in his cell at HMP Hewell on New Year's Eve in 2013.
The coroner said the prison's risk assessments for Mr Coley had been "inadequate and inconsistent".
The Prison Service said it would "look closely" at the inquest findings.
The Worcestershire coroner Marguerite Elcock ruled Mr Coley died as a result of suicide but said the way risk assessments were carried out at the prison and "insufficient communication" were also contributing factors.
In a statement Mr Coley's family said: "Despite his inner struggles with depression he blazed into our lives like a shooting star and unfortunately left us just as rapidly."
The family's solicitors, Cormac McDonough, said Mr Coley, who was serving a sentence for "a minor theft offence", was known to have had a history of self-harm.
A Prison Service spokesman said: "We will look closely at the findings of the inquest and any report the coroner may make to see what lessons can be learned, in addition to the Prisons and Probation Ombudsman's investigation."
A HM Inspectorate of Prisons (HMIP) reports into HMP Hewell in November said arrangements to induct prisoners were "often chaotic" and inspectors were "not assured that all new arrivals were fully assessed".