Before HM Senior Coroner Rachael C Griffin
At Bournemouth Coroner’s Court
Bradleigh Barnes, 23, was sadly found dead on 28 December 2019 whilst in prison at HMP/YOI Portland. He was due to be released shortly at an upcoming parole board hearing in January 2020.
The 2-week inquest has concluded with the jury having heard extensive evidence of serious failures at HMP/YOI Portland in the days and weeks leading up to Bradleigh’s death, but which were withdrawn from their consideration on a narrow point of law.
Background
Bradleigh died on 28th December 2019 at HMP/YOI Portland from a self-inflicted ligature. His grieving family believes he did not intend to end his own life and that his actions were a cry for help.
Bradleigh’s family remembers him as a cheerful, kind-hearted and protective kid, always full of life. He will be missed by all of his family, remembered and loved by everyone. There were series of failings uncovered during the inquest hearing, showing that Bradleigh did not get the help he needed and requested in relation to his mental health in the days leading up to his death. Bradleigh was on an open Assessment, Care and Custody Teamwork (ACCT) document at the time, meaning that he had been deemed to be at risk of suicide and self-harm. Therefore, the prison and prison healthcare service had accepted responsibility to
look after him and manage this risk, by keeping him under observations and undertaking detailed regular reviews of his mental health.
Bradleigh had a previous history of self-harm in the past, which was well documented on his paperwork. It had been identified that stress leading up to release from prison could be a trigger for self-harm, and this had been recorded as well. Despite the previous history, neither prison nor healthcare considered his records from previous incidents to fully assess his risk.
Evidence
During the two weeks of evidence, the inquest jury heard evidence from prison officers at HMP/YOI Portland and healthcare staff workers from Practice Plus Group. On 27 November, Bradleigh was referred to the mental health team at HMP/YOI Portland following a GP appointment. In the following days, Bradleigh made another self-referral to the mental health team. Due to horrendous 12-week delays in providing appointments, he did not manage to be seen before his death.
On the 23rd of December 2019, Bradleigh barricaded himself into his cell. Prison staff members gave evidence that this was out of character and highly unusual behaviour from Bradleigh who was ordinarily considered to be well-mannered, friendly, easily approachable, and always in a happy mood. The prison staff used force to break down his door and forcibly moved him into a ‘safer style cell’, a cell where the possibilities to self-harm were minimised. Following this incident, Bradleigh was placed on an ACCT document which outlines procedures for safeguarding prisoners at risk of self-harm. Several of these procedures were not followed – including not consulting with healthcare staff during the use of force incident and during the ACCT review process, a healthcare nurse inserting crucial information on a wrong prisoner’s medical records, inability to carry out an accommodation fabric check in Bradleigh’s cell and severe delays in offering mental health consultation to prisoners within the required timeframes.
The jury also heard evidence that HMP/YOI Portland regularly had insufficient mental healthcare or prison staff at the time of Bradleigh’s death. Mental healthcare nurses were regularly left without sufficient staff to carry out assessments of all the unwell prisoners who needed them and over 100 prisoners failed to attend their appointments in one month because there were insufficient prison staff to bring them to the healthcare unit. Prison staff were regularly not checking prison and healthcare records before carrying out suicide risk assessments due to pressure on their time and were routinely failing to ensure that members of mental heathcare staff attended ACCT reviews.
Despite concerning behaviour from Bradleigh on 23rd December, he was allowed to move back into his regular cell few days later, with no assessment or input from the healthcare team, and no ACCT review before the move. His cell was not properly checked by prison officers to identify an unsecured bed and several extra mattresses in his cell room, which Bradleigh used to barricade and ligature himself.
The jury heard evidence from Governor Ian Beckett, head of offender management at HMP/YOI Portland who admitted that the inability to carry out an accommodation fabric check prior to Bradleigh’s death was a missed opportunity to identify items in Bradleigh’s cell that could be used as a ligature or barricade.
On the 28th of December 2019, Bradleigh was found in his cell at around 8 o’clock, having barricaded the door and self-ligatured. He was pronounced dead shortly after. Leading up to his death, he had not been seen by a member of mental health team even once.
Conclusions
The Senior Coroner made a decision that these failures should not be left to the jury solely on the basis it was not clear if they made a difference to the outcome in Bradleigh’s case. It was, however, clear that there were extensive failures on the part of both prison and healthcare staff throughout the last month of Bradleigh’s life.
The jury were directed to record two admitted failures by Practice Plus Group, the healthcare provider at HMP/YOI Portland at the time, that they failed to see Bradleigh for a mental health assessment in an appropriate amount of time and mistakenly recorded concerns about Bradleigh on another prisoner’s record.
The Family are particularly upset that, despite days of evidence in which their officers and Governor candidly admitted that there were mistakes and failures in dealing with Bradleigh, Her Majesty’s Prison and Probation Service failed to make any formal admissions which could be recorded in the same way.
Despite the Senior Coroner’s ruling, the Family – who knew Bradleigh best – know that if Bradleigh had been properly supported at HMP/YOI Portland, he would have taken up that support and he would still be with us today. They are disappointed by the ruling and hope that the seriousness and extent of the failures at HMP/YOI Portland will be properly recorded and lessons will not just be learned, but properly implemented by all concerned.
The healthcare contract for provision of healthcare at HMP/YOI Portland has now been awarded to Oxleas NHS Foundation Trust and will take over from PPG shortly. The Family hope that Oxleas fully understand the failures that took place in Bradleigh’s time at HMP/YOI Portland and will take their own steps to ensure that these mistakes are not repeated.
Bradleigh’s family said: “We have been devastated by the loss of Bradleigh, which has only been made worse by the 3 year wait for his inquest and to hear prison officers and healthcare staff admit in the witness box how badly they failed Bradleigh. While we appreciate the Senior Coroner is applying the law as it stands today, it is frustrating and upsetting that after all this time the jury have been deprived of an opportunity to properly record those failures and deliver their conclusion.”
Bhaskar Banerjee of GT Stewart Solicitors said: “We are sadly all too familiar with such preventable deaths of vulnerable people in the prison service due to a lack of proper communication, document keeping and management of risk. Bradleigh’s case is all the sadder for the fact that he himself had sought help to manage his mental health, and no timely assistance was forthcoming. Our thoughts go out to his family. ”
Bradleigh’s family are represented by Bhaskar Banerjee and Keiu Kikas of GT Stewart Solicitors and Stephen Clark of Garden Court Chambers.
