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INQUEST PRESS RELEASE – For immediate release 20 July 2010

The jury at the inquest into the death of vulnerable prisoner Jonny Riley has found that a series of system failings led to his death.

Jonny Riley was found dead in the Healthcare centre in HMP Norwich on 12 March 2008. He was a vulnerable prisoner aged 28 suffering from long-term opiate dependency. Jonny had been taking methadone since 2007, when it was prescribed for him in HMP Peterborough. On being released, Jonny continued to participate in a methadone programme in the community to stabilise his drug addiction. On 8 March 2008 he was remanded in custody and transport officers opened a suicide and self-harm form because they were concerned about his wellbeing after he used his hand to break a window. The prisoner escort documentation also noted that Jonny had committed previous acts of self-harm. Jonny was transferred to HMP Peterborough where his prescriptions for methadone and diazepam were continued, but no ACCT was opened and a full reception screen was not completed.

On 11 March 2010 Jonny was transferred to King’s Lynn Magistrates Court where he had a fit in the cells. He was taken to hospital but discharged himself. Jonny had stated that he never received his prescribed medication that morning. He was then transferred to HMP Norwich, which did not have a methadone programme so Jonny was unable to continue with his medication. At reception Jonny made clear that he had been taking prescribed medication and had harmed himself in the past. It was also noted down that Jonny had had a fit earlier that day. No opiate substitute medication was prescribed. At about 9.15pm that evening Jonny had another fit. A request may have been made for an ambulance but none was actually called. A nurse found a previous prescription for diazepam from HMP Peterborough and used this to provide Jonny with a small dose of diazepam.

At around 7.45am on 12 March 2010 prisoners in the dormitory in which Jonny was located pressed the cell bell because he was having another fit. The nurse who attended arranged for Jonny to be moved to Healthcare, where his behaviour began to deteriorate. During a consultation with a doctor he threatened to cause damage if he had to stay in Healthcare. A little later Jonny walked into the centre office and told an officer that if he wasn’t allowed to leave he would smash his cell up. The same officer later went to see Jonny in his cell and Jonny stated that if he wasn’t returned to a normal location he would harm himself. Jonny then spat at him and kicked the door. Another officer then went to see Jonny and Jonny apologised for spitting. After this incident the hatch on Jonny’s cell door was kept closed. Jonny also appeared to have been abusive to a nurse and was therefore issued with an advice notice.

At about 2.30pm Jonny was given diazepam. An officer then returned and gave him the advice notice and Jonny asked that his hatch be left down, but was told it would remain shut. Later Jonny asked to use the landing phone, which did not work and he was told to complete an application form to have his numbers cleared. Jonny apologised to the officer for his earlier behaviour. Between 4.05 and 4.15pm this officer returned to Jonny’s cell to return his PIN phone number to him. Jonny thanked him. At approximately 4.50pm Jonny was found hanging in his cell. No ACCT was opened during Jonny’s time at HMP Norwich.

At the conclusion of the inquest on 19 July 2010 the jury in their narrative verdict found that Jonny Riley had killed himself whilst the balance of his mind was distressed. They concluded that the following contributed to his death:

HMP Peterborough

  • There were failures in the distribution and completion of relevant documents;
  • there were inadequate protocols and procedures in relation to the transferring of Jonny to an alternative prison;
  • there was an omission in the administration of his legally-prescribed medication on 11 March 2008.

HMP Norwich

  • There was a failure in the distribution, completion and opening of relevant documents;
  • there was a lack of adequate investigation into Jonny’s medical history and presentation throughout his stay at HMP Norwich;
  • these factors led to a failure to prescribe or administer any opiate substitute;
  • the continued use of the hatch was inappropriate;
  • no observations were made on Jonny between 16.15 and 16.54 on 12 March 2008;
  • the physical management of Jonny’s fits was appropriate but the follow-up was not.

Jonny Riley’s family said:

It has been extremely difficult to sit through the inquest and hear evidence about factors that contributed to Jonny’s death. However as a family we felt strongly that there had been failures on the part of the prisons in meeting Jonny’s needs and we are therefore pleased with the outcome, which acknowledges this. Jonny was a much-loved member of our family and we miss him everyday.

Deborah Coles, Co-Director of INQUEST, said:

What is particularly disturbing about this case are the many systemic failings and the lack of adherence to many of the policies and procedures designed to safeguard prisoners’ mental and physical health. The comprehensive rule 43 report of HM Coroner in this case must be reviewed urgently and the necessary learning disseminated across the prison estate. Jonny Riley was one of 20 prisoners who have died in HMP Norwich since 2000, and it is vital that decisive action is taken by senior management to address the failings identified.

Anna Booth of Coninghams Solicitors, who represented his family, commented:

The jury’s conclusions highlighted a series of shocking failures in both prison establishments, which contributed to the untimely death of Jonny Riley. Things as basic as not giving Jonny, a heroin addict, his legally-prescribed opiate substitution medication contrary to Prison Service policy, or opening an ACCT (self-harm watch) when he threatened to harm himself, were not done. We hope that lessons will be learned and Jonny’s death will not be in vain .

Jonny Riley’s family was represented at the inquest by INQUEST Lawyers Group members Anna Booth of Coninghams Solicitors and counsel Leslie Thomas and Deirdre Malone from Garden Court Chambers. .

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