A Walton inmate was found dead after being locked in his cell to have his lunch.
Paul Jones was being held on remand at the jail when he was discovered by another prisoner.
An investigation found he had spent the morning discussing his case with his solicitor, leading to claims he appeared "low" after the meeting.
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Mr Jones was taken to Walton, formally known as HMP Liverpool, after being accused of breaching a restraining order, assault and grievous bodily harm.
The 36-year-old was identified as having a risk of self harm and initially monitored four times an hour by prison staff.
Those checks were ended after three days but, after 16 days inside, Mr Jones was found to have taken his life on September 26, 2018.
His death prompted an investigation by the Prisons and Probations Ombudsman (PPO), which has now published its findings.
The probe found he was initially admitted to the prison’s healthcare centre to help him deal with severe alcohol withdrawal. That programme concluded, successfully, after five days.
During that time, the monitoring of Mr Jones also ended after his risk of self-harm was assessed as being low and because: “He engaged well with staff and told them that he had no thoughts of self-harm.”
He was moved onto a residential wing, I Wing, where he spent one week before his death.
On the morning of September 26, the PPO found he was visited by his solicitor for discussions about the allegations against him.
He then collected his lunch and, like others inmates, took it to his cell where he was locked in during lunchtime.
At around 1.45pm, as the cells were being opened, another inmate saw Mr Jones’ body and called for help.
Despite the efforts of staff and paramedics, he was pronounced dead at 2.25pm.
One of the lines of inquiry by the PPO was that he may have been upset by the content of legal documents he received that morning after suggestions he appeared “low” following that meeting.
However, he had ended those discussions by asking his solicitor to apply for his release on bail. The PPO found this “would suggest that their meeting was more positive than staff were led to believe”.
Allegations Mr Jones may have been “harassed or bullied” were also dismissed after investigators said they found no evidence to support the claims.
The PPO concluded: “Mr Jones had been at Liverpool for only 16 days before his death.
“Although staff correctly identified that he was at risk of suicide when he arrived at Liverpool, he was monitored under suicide and self-harm procedures [known as Assessment, Care in Custody and Teamwork (ACCT)] for only three days after this.
“I consider that the ACCT was closed prematurely while Mr Jones was undergoing alcohol detoxification.
“However, as Mr Jones had no recent history of self-harm or attempted suicide and seemed more settled, I consider that it would have been reasonable to have closed the ACCT once the detoxification had been successfully completed, and I do not consider that staff could reasonably have foreseen or prevented Mr Jones’ death at the time it occurred.
“We cannot say whether Mr Jones was upset by any of the legal paperwork he had in his cell.
“We are satisfied, however, that prison staff would not have been aware of the contents and did not have the authority to remove legal documents from Mr Jones’ cell.”
In response to the findings of the PPO, HMP Liverpool said specialist suicide and self-harm training package was being delivered to staff on a monthly basis and that actions identified within a prisoner’s ACCT ‘care map’ are “raised regularly at the governor’s morning meeting”.
It added: “A daily email is sent to all staff highlighting those prisoners due an ACCT or post-closure review. Since Mr Jones’s death, prisoners due a post-closure review are also reported at the morning residential meeting two days in advance of the post-closure review date, providing a prompt to the staff responsible for its completion.”
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