Date published: 10th September 2017

Sam was a vulnerable 21 year old man with a troubled history. On 25 August 2015 he was remanded to custody at HMP Liverpool. He served there until being transferred to HMP/YOI Hindley on 11th September 2015, before being returned to HMP Liverpool on 2nd October 2015, where he remained until his death on 1st April 2016.

On his initial entry to HMP Liverpool in August 2015, Sam alerted staff at the Prison to his history of mental illness and self-harm, and was placed on suicide and self-harm prevention procedures, known as ACCT (Assessment, Care in Custody & Teamwork). During his two separate stays at HMP Liverpool, he was placed on ACCTs 3 times in total, due to his confessed risk to himself.

On 27th March 2016, Sam was attacked in prison, the culmination of a campaign of bullying. He reported this incident to the Prison, and on 30th March 2016, the day before his death he alerted the governing staff of the Prison to both the bullying and his strong thoughts of self-harm. Despite this, the prison did not place him on an ACCT.

At 22:16 on 1st April 2016, Sam was found hanged in his cell. Staff and the on-duty Prison Nurse attempted resuscitation, before he was pronounced dead by paramedics at 22:52.

Following an eight day inquest at Liverpool Coroners Court, a ten person jury found that Sam had intended to end his own life.

In a critical narrative, the jury found that the bullying campaign contributed to his death, and that the Prison should have placed Sam on an ACCT. During the Inquest, a number of operational issues were raised regarding HMP Liverpool. Notably, whilst the majority of cells at HMP Liverpool have anti-barricade doors which can be removed if a prisoner blockades their doors to prevent staff entry, Sam was held in a cell without these specialist doors.

Following the verdict, the Coroner has compiled a Prevention of Future Deaths report, known as a Regulation 28 document, in which he identified that anti-barricade doors should be used whenever practicable for vulnerable prisoners.

Sam’s family are understandably devastated by his death but are pleased that the jury identified the issues that led to Sam’s death. They hope that the prison and the wide prison service will now implement changes to ensure that incidents like this are not repeated.

A solicitor representing the family, said:

“This is yet another sad death of a vulnerable young man at HMP Liverpool. It is important that the jury recognised the dangerous impact of bullying on vulnerable prisoners, the need for greater care for these individuals by prison staff, and the substantial effect that up to date prison infrastructure has on suicide and self-harm prevention.”

The family is represented by Broudie Jackson Canter Solicitors and Garden Court Chambers.