A man killed himself in jail after prison officers failed to respond to his calls for help for more than 40 minutes, a jury has concluded.
Andrew Brown, from Chesterfield, was found hanging in his cell on the induction wing of HMP Nottingham on 12 September 2017 and died in hospital five days later. He was the second of five men to die in HMP Nottingham in less than a month.
The 42-year-old, who had been recalled to prison on 18 August 2017 after being released on license four days earlier, had a history of self-harm and suicide attempts, the jury heard.
Mr Brown is said to have expressed thoughts of ending his life in earlier court sessions and when he arrived at the prison, suicide and self-harm monitoring procedures were opened – but they were closed three weeks later despite him having disclosed intentions of harming himself.
On the morning of 12 September, he was brought out of his cell to the prison reception and told in error that he was going to be released. The jury found that suicide procedures "should have been re-opened... as soon as Andrew was told that the decision to release him had been revoked.”
Mr Brown was taken back to his cell, where he pressed his cell bell four times in the hour before he placed a ligature around his neck. The last of these emergency calls was not answered for 43 minutes, despite the governor's orders to ensure cell bells are answered within five minutes.
At the inquest, the prison officer accepted he had been “pottering around the office” rather than answering the emergency call, while evidence was also heard that the emergency cell bell on the induction wing was regularly taped over by staff to muffle the sound.
After Mr Brown was taken to hospital, a note was found in his cell where he raised a number of concerns, including his aborted release that morning and failure to explain it to him, the lack of healthcare and his lack of access to a job, to chapel worship and to regular hot water.
In evidence, the prison accepted that these were “basic” concerns which should have been achieved.
The jury heard evidence that despite being referred twice for a mental health assessment which should have occurred within five days, an appointment was not made for Mr Brown for 32 days. He was still waiting to be assessed when he died.
They found that “Andrew did not receive appropriate and timely assessment and support from the mental health team”.
There were seven deaths in HMP Nottingham in 2017 and a further six in 2018. In January, the prisons watchdog took the then unprecedented step to issue an Urgent Notification, stating that the prison was “fundamentally unsafe” for the third time in a row.
At the inquest the current prison governor, Phil Novis, accepted that the prison had been in crisis and had failed Mr Brown. Asked whether what the Prison Inspectorate described as the “shocking” failure to learn lessons from previous tragedies contributed to his death, however, he replied: “No”.
Mr Brown’s family described him as much-loved brother and a man of strong Christian faith.
Kevin Brown, his brother, said he was “badly failed” by HMP Nottingham, adding: “It would have been obvious to anybody how vulnerable he had become, and it was shocking to hear how unsafe the system in [the prison] was when Andrew was there.
“He was denied the mental health care he needed and he was let down by those who should have been keeping an eye on him.”
Deborah Coles, director of Inquest, said: “Nottingham prison had long been forewarned about unsafe practices, including by HM Inspectorate of Prisons. Yet the inquest jury found no improvements had been made prior to Andrew’s death.
“Warnings from coroners and inspection and monitoring bodies have been systematically ignored by the prison service and government. The cost paid by this inaction is yet more preventable deaths.”
Jo Eggleton of Deighton Peirce Glynn Solicitors, who represented the family, said the failings in this case were “numerous, obvious and shocking”, and that despite inspectors “repeatedly” pointing out the same basic failings, the prison had “repeatedly failed to put them into practice”.
“The governor has accepted that Andrew was failed – but also seemed to demonstrate a worrying lack of understanding of the consequences of failing to learn lessons for the future,” she added.
A Prison Service spokesperson said: “We wholeheartedly apologise for the failings in this case and our thoughts remain with Andrew Brown’s loved ones.
“There have been significant changes at HMP Nottingham since his tragic death. We have hired more staff, reduced the prison population, and introduced weekly checks to make sure all cell call bells are met within the five minute recommendation.
“We have also made improvements to the induction wing, opened a wellbeing centre, and introduced the key worker scheme so each prisoner now has dedicated support from a prison officer.”