Date published: 15th February 2018

James Flynn, 34, of Merthyr Tydfil, was found hanging in his cell during the evening of 27th April 2015 at HMP Guys Marsh. His death was confirmed by paramedics at 10.14pm. James was first admitted to prison in 2005, and was transferred to HMP Guys Marsh on 9th April 2014. He suffered from Attention Deficit Hyperactivity Disorder (‘ADHD’), as well as having recognised traits of Emotionally Unstable Personality Disorder (also known as ‘Borderline Personality Disorder’).

The type of sentence that he received meant that he was detained indefinitely, until such time as he was able to persuade the Parole Board that he should be released. For prisoners in this position, the only guide as to the length of detention is the ‘tariff’ – i.e. the minimum period of imprisonment. In James’ case this was two years and one month. At the time of death, James had been in prison 11 years beyond the expiry of his tariff, and he still had no indication of a possible release date. James had been working hard towards release, and had taken part successfully in seven offender behaviour programmes.

However, he underwent a Parole Board review on 4th December 2014 where it was decided that he needed to complete a further programme in a PIPE unit (Psychologically Informed Planned Environment). The PIPE programme is focused upon helping prisoners progress. However, it is a very lengthy programme, which would add at least 18 months, and potentially even several years, to his sentence. The suggestion that James should complete such a programme before being released came from one of James’ Probation Officers, and he had not been told that this suggestion would be made in advance of the parole hearing, and the inquest heard criticism from other witnesses of this omission. This news was very difficult for James to hear and continued to trouble him during the last few months of his life. The effects are likely to have been exacerbated by the effects of the Personality Disorders from which James suffered. Furthermore, in December 2014, James lost his Mum and in March 2015 he learnt of his Father’s cancer diagnosis.

The jury heard that James was placed on an Assessment, Care in Custody and Teamwork (ACCT) document on 9th April 2015, following thoughts of suicide. The ACCT process is meant to help identify and care for prisoners at risk of self-harm and suicide. The ACCT was closed later the same day without holding a multidisciplinary review. Throughout April, James expressed thoughts of dying in prison and was clearly distressed by recent events in his life.

On 27th April 2015 James informed prison officers that he felt unsafe and a transfer to HMP Dartmoor was arranged for the next day. That afternoon, James was seen by a mental health nurse and was noted to be very high on the scale of depression and anxiety. The jury heard that this nurse was not fully aware of James’ diagnoses, and that had he been so, he would have re-commenced the ACCT procedure to reduce the risk to James. That evening, however, at 9.15pm James cut his wrist and told one of the officers that he was going to kill himself. James was left unattended while an ACCT was opened. However, when the officer returned to the cell, the observation panel had been blocked and attempts to get a response from James failed. Back-up was called at 9.25pm, however the jury heard that the urgency of the situation was not made clear. Officers entered the cell at approximately 9.34pm and upon finding James hanging, medical assistance was called. Attempts were made to resuscitate but sadly he was declared dead at 10.14pm.

The jury returned a conclusion of suicide on 18th January 2018. In coming to their conclusion they considered the difficult circumstances that James was going through. This included the bad news he had been receiving in the months preceding his death in his personal life and the likely impact of the sudden and unexpected news that he would have to spend a substantial period completing the PIPE programme, even after having spent over a decade post-tariff in prison. The conclusion of ‘suicide’ does not indicate a finding that James had a clear, settled intention to end his life in advance of the moment that he cut himself on 27th April. The Coroner directed the jury that all that matters is whether James had the intention to take his own life at the time of the act that ended his life. The family feel very strongly that James was not suicidal, and the jury heard a great deal of evidence that supported this view. It should be emphasised that the personality disorders from which James suffered can lead to intentions of being unsettled and fleeting, thus causing people to act impulsively.

The Coroner will be producing a Preventing Future Death report due to concerns that on a national level there is no guidance with regards to sharing Parole Board dossiers with healthcare staff to enable them to deal with any concerns and risks this may pose to prisoners. The Coroner will also request that consideration is given to utilising telescopic cameras to access cells whereby observation panels have been covered by prisoners.

Jenny Fraser, solicitor representing the family, said:

“This is a very sad death of yet another prisoner. It is crucial that lessons are learnt by all to prevent any future deaths from occurring. It is vitally important that all prisoners are receiving the correct medical treatment, appropriate monitoring and safeguards are put in place to protect current and future prisoners.”

The family is represented by INQUEST Lawyers Group members Jenny Fraser and Leanne Devine from Broudie Jackson Canter Solicitors and Paul Clark from Garden Court Chambers.