We recently acted in an inquest for the family of SOR, who sadly took his own life whilst an inmate at HMP Wandsworth, two years after his brother also took his own life whilst remanded at HMP Belmarsh. Following a suicide attempt, he was transferred to a secure psychiatric hospital for 17 months. He was then transferred to HMP High Down, where he was monitored in secure healthcare wing, as he continued to be at high risk of self-harm. When it came to his criminal trial, the decision was taken to move him to Wandsworth, which was closer to the Central Criminal Court. Nurse leads at HMP High Down urgently contacted Wandsworth and told them that they should only accept him if they would put him on a healthcare wing due to his suicide risk. It was well documented in his paperwork that a conviction in his trial would be a trigger for suicide. A conviction was supposed to prompt a review of his mental health, with a view to putting him in a constant watch cell where he would be monitored 24/7. SOR was convicted on 15 December 2020. Despite a psychiatrist and nurse promptly flagging he now needed to be reviewed in and possibly put on constant watch so that he wouldn’t hurt himself, none of the prison officers on duty carried out the review, passing the task between themselves with no one taking responsibility and he was only briefly checked once an hour. SOR was discovered suspended by a ligature in his cell at 11:17pm on 15 December.

Following a two inquest into his death between 15 and 26 May, a jury found multiple systematic failures as regards the management of prisoners at risk of self-harm at Wandsworth, highlighting the inadequate communication between prison and healthcare staff as well as the incomplete policy documents (including ACCT reviews). We are now pursuing a civil claim on behalf of the family.

The family was represented by Bhaskar Banerjee, assisted by Keiu Kikas of our Actions against the Police Team. Counsel was Sarah Hemingway of Garden Court Chambers.