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."
Read more: Mum's desperate plea for better safety at Swansea Prison where her son was found dead
The report states that Lee, described as a much-loved member of his family, was undergoing detoxification from alcohol and had been given certain medication to take both in police custody and then in prison. It adds that there were "historic risk markers" for suicide and self-harm on the police custody and prison systems.
There was also evidence in prison medical records showing that Lee had been prescribed anti-depressants for depression and anxiety when in HMP Swansea on previous occasions. The coroner states in the report: "On Saturday, January 13, 2018 the prison doctor reviewed Lee's notes but did not prescribe Lee's anti-depressant medication and did not write up Lee's prescription for his alcohol withdrawal medication.
"Lee was told that the doctor had not written up his alcohol withdrawal prescription and this made Lee anxious at the medication hatch. However, at the nurse's discretion, Lee was given his evening dose of his alcohol withdrawal medication.
"Shortly afterwards Lee can be seen on CCTV speaking to two prison officers in an animated way and for approximately one minute. I have been unable to establish what Lee was saying. Shortly after this interaction Lee can be seen walking in the direction of the area that houses the post box holding a piece of paper and envelope and then returning to his cell empty-handed.
"Lee was locked in his cell at around 4.30pm and was not checked until he was founded by a nurse commencing the first of three nightly checks shortly after midnight. After Lee's death a letter was found in the HMP Swansea post box written by Lee to his partner which indicated that at an earlier time Lee was fine but on the other side Lee had written: 'they stopped my meds goodbye I quit loved you'. It was clear from the evidence that this letter could only have been posted on the Saturday."
The coroner said there is a risk that future deaths of this nature will occur unless action is taken. On January 4, 2018, nine days before Lee died, HM Inspectorate of Prisons published a critical report condemning HMP Swansea’s "complacent and inexcusable" approach to the safety of vulnerable prisoners and failing to respond effectively to high levels of self-harm and suicides of new prisoners.
HM Inspectorate of Prisons reported that there had been four self-inflicted deaths in HMP Swansea within a week of arriving. The next report by HM Inspectorate of Prisons issued in 2020 found that there had been two further self-inflicted deaths since the last inspection.
A narrative conclusion was recorded following the inquest at Swansea Coroners' Court where the medical cause of death was confirmed as pressure on neck (hanging). The Ministry and Justice has been approached for comment.
A spokesman for Swansea Bay University Health Board, which is responsible for healthcare at the prison, said: "We would again express our condolences to Mr Evans’ family. Following his very sad death in 2018, an investigation was carried out and a comprehensive action plan was agreed between HMP Swansea and the health board.
"This has seen healthcare provision at the prison expanded and strengthened. Details of the actions taken have been shared in full with the coroner."
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