Two private companies with lucrative prison and police contracts across Britain have been criticised by a jury for the role they played in the suicide of a vulnerable inmate with mental health problems.
Shaun Beasley, 29, was found hanging in his cell at Parc prison in Bridgend, south Wales in August 2010. He had a history of self harm and had previously made several serious suicide attempts.
A jury at the inquest into his death ruled that he "took his own life in circumstances contributed to by neglect of healthcare and prison".
Parc prison and young offenders institute is the only private prison in Wales. It is run by G4 Securicor, the second biggest commercial employer in the world, which has six prison contracts with the Ministry of Justice.
At the time of Mr Beasley's death, G4S had sub-contracted out the healthcare services to Primecare Forensic Medical Services, which provides primary care or GP like services in prisons, police and other secure institutions across the country.
Prison inspectors found "chaos and crisis" within Parc's healthcare unit shortly after Mr Beasley death which they said was "foreseeable and preventable".
Inspectors said the provision of care and treatment by Parc to Mr Beasley was "grossly inadequate" leading to a systematic failure to protect him from suicide.
Similar systematic failures were identified in the healthcare wing run by Primecare at the 2009 inquest into Aleksy Baranovski death at Rye Hill in 2006. G4S took over running Rye Hill in 2008.
Experts last night called for urgent action to increase accountability of private contractors.
Deborah Coles, co-director of Inquest said: "Shaun's tragic death was an accident waiting to happen. What is deeply concerning is that Parc's healthcare was allowed to descend into such a state of chaos, again.
"This begs the question, what control and accountability is in place when things go wrong with private contractors? What must happen now is national scrutiny and learning to address these deficiencies."
In May 2007 Shaun was given an indeterminate sentence with a minimum tariff of two years and 145 days.
He moved from Littlehey prison to Parc just two weeks before his death, in order to complete a course that would make him eligible for parole. But, once he had arrived at Parc he was informed the course was not in fact available, and he would have to wait two to three years.
At the time of his death he had served over three years.
The evening of his death he rang his sister to say goodbye because he could not cope any more. The family immediately rang the prison to alert them, but no action was taken, despite the fact Shaun was considered at risk of self-harm. He was found hanging in his cell a few hours later.
The jury at Aberdare Coroner's Court was told about desperate nurse shortages as Primecare had not filled vacancies in the run up to the end of their contract with G4S.
Louise Jeory, employed as Healthcare Manager at the time, told the jury about poor staffing levels, inadequate training, poor record keeping and low morale. She admitted that the healthcare unit was "compromised and unsafe" at the time of Shaun's death and that a breakdown in systems and a lack of competence contributed to his death.
Donna Ridgley, Shaun's sister, last night said the family were devastated that their warning phone call had been ignored. "The verdict has confirmed what we have always felt; we have always felt that Shaun had been let down and it is very important to us that there has been public recognition of this."
G4S's Janet Wallsgrove, Director of Parc, said the coroner was satisfied that the correct improvements had been made. "Due to our concerns regarding inadequate provision, arrangements were already in place to bring [health] services in house and this occurred shortly after Shaun Beasley's death... Significant changes have taken place to improve the care given to vulnerable prisoners and those at risk.
Sarah Campbell, Operations Director for Primecare's secure health services, said: "We are deeply sorry that the care that Mr Beasley received was not up to the required standards. Our services have improved greatly since this tragic incident in 2010."