Overworked guards at a troubled London prison failed to notice when one of the inmates died in his cell, a coroner has found.
Brandon Johnson, 40, was found dead in cell 29 at HMP Wandsworth after suffering a heart attack, driven by a history of chronic cocaine abuse.
Inner West London coroner’s court heard prison officers had been instructed to make regular checks on Mr Johnson, and looked in on his cell from 4.30am on the day of his death, September 12, 2019.
But it was not until late afternoon that the alarm was raised, when there was evidence that he had been dead for some time.
Coroner Paul Rogers, who oversaw the inquest, has now issued a report highlighting problems at the prison, in an attempt to avoid future deaths.
“I heard evidence that Brandon was not discovered as deceased until the late afternoon of 12th September 2019 despite a number of attendances at his cell by prison officers and other staff”, he wrote.
“Rigor mortis and pooling of the blood had been identified.
“I was told various checks had been undertaken since 0430. I heard evidence that whilst staff knew they needed to obtain positive responses from prisoners and should assess whether the person is alive and breathing, they had little time in which to do this when combined with other duties.”
The prison in south London was put into special measures in May this year due to reports of serious overcrowding, violence among inmates and towards staff, vermin infestations, and the widespread use of drugs.
Chief Inspector of Prisons Charlie Taylor said inmates received “poor outcomes” due to “systemic and cultural failures” which he blamed on “poor leadership at every level of the prison, from HMPPS and the Ministry of Justice”.
“Many well-meaning and hard-working leaders and staff persevered at Wandsworth, and their resilience was impressive, but they were often fighting against a tide of cross-cutting, intractable problems that require comprehensive, long-term solutions”, he added.
The Ministry of Justice responded by pledging to spend £100 million on improvements over five years, as well as deploying extra specialist staff to the jail.
A jury concluded Mr Johnson died from cardio-respiratory failure, contributed to by heart disease and cocaine abuse.
The coroner heard evidence from prison staff about checks they made on the day of his death, and concluded he is “not confident…that staff had sufficient time to properly check on inmates and obtain positive responses or note obvious signs of life”.
“The checks that were made were for a matter of seconds, and I was not satisfied that the signs of life said to have been noted were sufficiently obvious or reliable to have given appropriate reassurance, or that signs of life were actually being looked for rather than as being incidental to other observations”, he wrote.
“I am concerned whether all appropriate measures are being taken to perform robust checks at appropriate times that elicit positive responses to indicate that a prisoner remains alive.
“In addition, I am concerned about how the prison satisfies itself that staff know how and when to perform these checks, what that consists of, and in relation to signs of life/positive response what those are meant to be and where that is set out in the training of staff.
“Further if checks are performed which elicit a positive life response how are those recorded, who checks this is being done, in what form and how often.”
The report has been provided to Mr Johnson’s family and the Ministry of Justice, while the governor of HMP Wandsworth has been ordered to formally respond to the coroner’s concerns before the end of November.
