Serious failings by both prison and healthcare staff may have contributed to the death of a young man in his cell, a coroner has concluded. Robert Lee Evans, a prisoner at HMP Swansea with a history of anxiety, depression, and alcohol addiction, was found hanged in the early hours of January 14, 2018, just over 24 hours after being put in custody.
Assistant coroner Kirsten Heaven said prison staff "probably" failed to adequately assess the 37-year-old's risk of suicide and self-harm. She added that there may not have been an adequate system of checks in place for Mr Evans, known as Lee, despite him being in the early days of prison and undergoing alcohol detoxification.
In addition she said that the prison doctor failed to prescribe Lee's antidepressants which "possibly made a more than minimal contribution to Lee's death". In a report to prevent future deaths published following his inquest the coroner states: "The prison and medical staff within the prison probably did not take all appropriate steps to safeguard Lee when he was in prison custody, for example by not opening an ACCT (assessment, care in custody, and teamwork), and by the way prescription information was communicated to Lee. This probably made a more than minimal contribution to his death."
