An inquest into the death of a remand prisoner who had been on suicide and self-harm watch shortly before he died has criticised prison officers for being unaware that his access to razor blades should have been monitored.
Lance Clark, 53, died on 28 November 2019 of a haemorrhage after he self-harmed with a razor while in prison on remand at HMP Chelmsford, Essex. The jury, which sat for two weeks, concluded that prison and mental healthcare staff did not manage Clark’s risk of self-harm appropriately, which probably contributed to his death.
Clark had a long history of anxiety, depression and self-harm. He had been at HMP Chelmsford for four months having been charged with public order offences and had self-harmed on 14 occasions using a razor blade or a sharp item. He was taken to hospital for treatment on eight occasions due to the severity of his self-harm injuries.
Although Clark was being managed under procedures to prevent suicide and self-harm, known as ACCT (assessment, care in custody and teamwork), prison and mental health staff consistently underestimated and misjudged his level of risk. At 18 of his 25 ACCT case reviews it was agreed that Clark’s level of risk was “low” and only twice did the case review consider that Clark was at high risk of self-harm.
In October 2019 his ACCT was closed. The Prisons and Probation Ombudsman investigation found that Clark’s inability to manage his stress other than by self-harming, and his worries about antidepressants and the stress of his upcoming trial, “remained acutely unresolved” after the “premature” closure of Clark’s ACCT. He was not put on a mental health plan and a risk management strategy was not put in place when Clark’s ACCT monitoring was stopped.
Despite his history of self-harm, neither prison nor mental health staff discussed his access to razors during ACCT case reviews. Witnesses at the inquest said that a Prison Service safety briefing in April 2019 stating that access to razors must be discussed at ACCT case reviews was not circulated to any prison or mental health staff.
For prisoners at high risk of harm, the briefing included a requirement to supervise their use of razors or provide alternatives such as electric razors or hair removal cream. Staff said they were unaware of guidance on access to razors for prisoners being monitored under suicide and self-harm procedures. HMP Chelmsford said the briefing had been circulated.
When Broomfield hospital in Essex raised concerns around Clark’s access to razor blades, after his frequent attendances at A&E due to cuts inflicted by razor blades, HMP Chelmsford responded that no action was required.
Clark repeatedly told prison and mental healthcare staff that he was stressed about his upcoming trial. On the evening of 27 November 2019, the day before his death, he threw a plate of food at the wall in the prison servery, which was out of character. The next morning he was removed from his wing-cleaner job as punishment. Clark had repeatedly said the job had enabled him to keep busy and reduced the time he spent alone in his cell, “spiralling” in negative thoughts.
The prison was criticised for multiple failures, including not managing him under enhanced ACCT procedures that would have involved senior prison managers, failing to provide preventive care or support, including any 1:1 time with a mental health nurse, and the way he was dismissed from his cleaning job. The prison never involved Clark’s family in the ACCT process, and did not inform them that he had been repeatedly hospitalised after self-harming.
Clark’s death was one of 14 self-inflicted deaths of prisoners at HMP Chelmsford since 2016.
His mother, Pauline Clark, said: “My Lance was a lovely son. He was absolutely devoted to me and me to him. It was known by healthcare and prison staff that Lance’s self-harming was serious and increasingly life threatening. Despite this, they failed to put in place the necessary support, leaving him vulnerable and unsupported. Lance was let down. I just hope other families don’t have to be put in this position.”
Sam Hall, a solicitor at ITN Solicitors, representing Lance’s family said: “The failure to adequately risk assess Lance’s access to razor blades was particularly shocking. The April 2019 national safety briefing on restricting prisoner’s access to razor blades should have been implemented before Lance’s death and action should have been taken when Broomfield hospital raised concerns about Lance’s access to razor blades. These failures increased Lance’s risk of self-harm and contributed to his avoidable death.”
Lucy McKay, a spokesperson for the charity Inquest, which represented Clark, said: “HMP Chelmsford has long been on notice about their failure to support people in mental health crisis, which has had devastating consequences for so many. Yet recommendations arising from inquests, investigations and inspections have been ignored. This has allowed preventable deaths like Lance’s to continue.
“HMP Chelmsford and prisons nationally must consider the shocking evidence of this inquest, and ensure urgent action is taken to prevent such serious failures in future. More broadly, the government must take action to ensure people in such serious mental health crisis are not held in prisons but supported in specialist healthcare settings.”
A Prison Service spokesperson said: “Our thoughts remain with Mr Clark’s family and loved ones. We will carefully consider the inquest’s findings and respond in due course.
“We are investing £37m over the next three years to make prisons safer through improved suicide and self-harm awareness training, prison helplines and ligature-resistant cells.”
In the UK and Ireland, Samaritans can be contacted on 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org.
