Jury find series of failures in safeguarding at HMP Swansea as inquest into death of Oliver Jones concludes

Before Senior Coroner, Colin Phillips (and a jury)
Swansea Coroners Court
3 to 7 February 2020

Oliver Jones [Huxter], known to his family as Olly, tragically died on 11 March 2014 in HMP Swansea after being discovered suspended by a ligature in his cell.

Olly, 26, had entered HMP Swansea on 19 February 2014 with a 166 day sentence. On his first night he told the nurse that he wanted to ‘kill himself by any means necessary’ and was tearful during this interview. Olly had a history of depression, previous self-harm and suicide attempts. He was then placed on an ACCT. He remained on this for nine days, over which time he underwent four case reviews. The Prison and Probation Ombudsman acknowledged, following Olly’s sad death, that these reviews were not consistent in terms of staff, and were not sufficiently multi-disciplinary.

Olly was also referred to Lighthouse, the mental health care team within the prison, but was not scheduled for an appointment for almost four weeks from the time that he was referred. Sadly, the date of his appointment was the following Monday, after he died.

The ACCT was closed on 28 February 2014. During the inquest, it was not clear through evidence that other staff knew that his mental health appointment was still outstanding. This revealed issues with the Care Map, which forms part of the ACCT, in terms of communicating information to other staff about which actions had been completed. It was also not clear if triggers for decline in Olly’s mental health were clearly communicated between staff members.

On 11 March 2014 Olly asked to speak to the Chaplin, as he was concerned over when he would be seeing his family. He was later discovered by his cell mate, who was returning from hospital, suspended from a ligature in their shared cell. Staff rushed to his aid, but sadly he was later pronounced dead by paramedics.

There have been multiple issues with the Court, which include holding the inquest six years after Olly’s death, preservation of evidence, and disclosure of information to the family. The family were still receiving hundreds of pages of disclosure two weeks before the inquest, with other documents coming in on the Friday before the inquest began, after asking for documents for the past six years. Parts of the ACCT document have been lost, so it is impossible to confirm exactly what staff knew at the time.

The Court has blamed this on a difficulty with technology and their online portal. The family have suffered a considerable amount of distress and have struggled with the grieving process due to the delays in this final Inquest being heard.

At the conclusion of the inquest the jury returned a narrative, finding:

• The ACCT reviews were completed with inadequate attendance by multidisciplinary teams from the third case review through to the post closure review
• The Care Map was incomplete in that outstanding issues were not updated to the Care Map
• Had the Care Map been appropriately updated the ACCT could, and should, not have been closed whilst the outstanding appointment with Lighthouse had not been completed
• The frequency of formal ACCT training was found to be insufficient
• Evidence of communication failures were suggested by the lack of multidisciplinary attendance, from the third case review through to closure

There was sufficient evidence that the prisoner had significant mental health issues at the time of his initial custody.

Media release re-posted from INQUEST.