Prison staff were given "inadequate" information about a mentally ill young man who was found dead within hours of being transferred from the healthcare wing of Brixton Prison, an inquest was told.
Cesar Augusto Granja Lara was found apparently hanged in a cell in September 2007; he was 22 years old. He had suffered from acute episodes of psychosis which included hearing derogatory voices, seeing monsters and paranoid delusional thoughts that at times made him feel suicidal, the court heard.
But there was a suspicion by some healthcare staff that in the days before his death he was embellishing his symptoms in order to try and avoid a long prison sentence by being transferred to hospital.
Dr Andrew Forrester, the consultant psychiatrist in charge of mental health at Brixton prison at the time, said he thought Granja Lara's underlying schizophrenia was stable and he had not expressed any suicidal thoughts during their last meeting - five days before he was found dead.
Dr Forrester told the inquest that there was a "disconnect" between the distressing symptoms reported such as voices telling him that he would be raped in the prison wing, and his behaviour, making him suspect that Granja Lara was exaggerating his symptoms for secondary gain.
The court heard that two days after Dr Forrester decided that he was suitable for transfer to the prison wing, Granja Lara told a nurse that he was hearing voices that his girlfriend had been raped and voices telling him to kill himself. The court heard that there was no record of this information or any discussion taking place in the medical records.
Dr Forrester admitted that the information on the transfer form completed by the healthcare nursing staff to the prison wing was "limited". But he said that there was consensus among the multi-disciplinary team that it was in Granja Lara's "best interest" to transfer him to the prison wing where there was greater access to the library and occupational therapy, and the healthcare wing in 2007 was "not fit for purpose".
Dr Forrester referred him to the mental health outreach team, which looked after between 50 and 60 mentally ill inmates in the prison wing, but Granja Lara died before he could be seen.
Dr Gregor McEwan, a GP providing primary care to prisoners, was called to the cell at 10.15 on 5 September 2007 where he found nurses trying to resuscitate Granja Lara. "There was no sign of a heartbeat, no sign of life... he had been dead for some time; the body was very cold, cyanotic and very stiff."
The court was told that there may have been a delay in opening his cell that morning due to an "acute staffing shortage" as there was only two prison staff when there should have been five.
The expert medical witness, Dr Jonathan Shapero, who is a forensic psychiatrist with 29 years experience, said that the transfer to the prison wing was reasonable but that he would have expected the prison staff to "keep an eye" on Granja Lara due to his mental illness and the fact he'd been considered a suicide risk only days earlier. He said that the information on the transfer form was "inadequate".
Dr Shapero told the court that it was "a matter of some anxiety" that it was not at all unusual for a mentally ill man like Granja Lara to be held in prison wings.
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