Inquest into the death of Matthew Stubbs concluded today
2 November 2015
Mathew Stubbs was a 36 year old man who struggled with mental health issues and ADHD for most of his life. He also suffered from PTSD and was suffering with traits of emotionally unstable personality disorder. Despite his problems, his family described him as being a person with a huge heart and beautiful smile who adored his children and was loving towards his family.
On the 29th July 2013, Matthew died at Leeds General Infirmary, after being found hanging in his cell in the segregation unit at HMP Leeds on 26th July. Matthew was known to have made previous serious attempts on his own life both in the community and at least once when in prison.
The Inquest heard that when Matthew was first recalled to custody and arrived at HMP Leeds on the 15th July his psychiatric history was noted in addition to the fact that he had not been taking his medication for ADHD which controlled his symptoms of impulsivity, mood swings, restlessness and engaging in risk taking activities.
A referral was made to the Mental Health In Reach Team and an appointment was arranged for him to be seen by the Psychiatrist on the 26th July. During that time Matthew was not assessed by a member of the Mental Health In Reach Team. A prison GP prescribed Matthew with 18mg of the Concerta (the lowest dose, and less than Matthew’s normal dose) due to the fact that he had not taken his medication for a period of time.
On the 23rd July, despite the fact he had not yet been assessed by a member of the Mental Health In Reach Team or a psychiatrist Matthew was transferred to HMP Everthorpe without his ADHD medication. Matthew exhibited extremely aggressive and violent behaviour and commenced a dirty protest which was completely out of character. He also became disengaged with staff. He was placed in a special accommodation cell. He was taken back to HMP Leeds the next day as HMP Everthorpe did not have the necessary expertise to manage his condition.
On the 24th July, Matthew was returned to HMP Leeds and taken straight to segregation. He had no medication on the 24th and received a delayed dose on the 25th. On the evening of the 25th July Matthew self harmed in his cell and an ACCT was opened. He was retained in segregation, but no exceptional reasons were identified or recorded to justify this. On the morning of the 26th, Matthew refused his medication and food. Despite his continued aggressive and bizarre behaviour Matthew was not examined by a doctor or any mental health practitioner. Later that morning Matthew was found hanging in his cell.
Evidence was heard from an Independent Consultant Psychiatrist who reviewed the care received by Matthew. His evidence was that it was likely Matthew was suffering from symptoms of his ADHD including restlessness, inattention, hyperactivity and impulsivity and this behaviour likely lead to his recall and also his behaviour when transferred to HMP Everthorpe. The expert was critical of the lack of urgent assessment being carried out on Matthew whilst he was in custody.
After four weeks of evidence the Jury returned a narrative conclusion. HM Senior Coroner Mr Hinchliffe advised he would be using his powers under Regulation 28 to make a report due to concerns that arose in Matthew’s case. He intends to touch upon issues relating to suicide and self harm management training, process/policies/procedures and inadequacies regarding communication between the different healthcare teams. These recommendations echoes the ones made by Prison Probation Ombudsman who was also critical about the circumstances which led to Matthew’s death.
The family of Matthew said:
“The thing that hurts the most is that we believe Matthew’s death was completely avoidable. Matthew was not depressed and we do not believe he wanted to die; he just wanted someone to listen to him and to help him. After listening to four weeks of evidence we believe that there were failings in Matthew’s care and the cumulative effect of those failings means we as a family have to live the rest of our lives without him with us.”
Deborah Coles, co-director of INQUEST said:
“It is unacceptable that as a society we let someone like Mathew die in this shocking way in a segregation cell. Why are the mechanisms which were put in place after countless deaths in custody, not working to safeguard the lives of vulnerable people with serious mental health problems? We know that in a matter of months there was another death in Leeds prison in the segregation unit. These deaths highlight prison is no place for people with mental health problems”
INQUEST has been working with the family of Matthew since July 2014. The family is represented by INQUEST Lawyers Group member Gemma Vine from Lester Morrill Solicitors in Leeds and barrister Richard Copnall from Park Lane Plowden Chambers in Leeds.
‘No other organisation has worked so closely with bereaved families throughout the investigation and inquest process. INQUEST has a unique insight into the daily difficulties families face while striving to cope in the aftermath of a death in custody. The Skills and Support Toolkit can provide you with practical advice needed to continue and maintain your day to day life at a time when even the simplest of tasks can seem insurmountable, or help you develop the skills needed to mount a campaign. ’
– Mother of a child who died in prison