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Jury finds neglect at HMP Liverpool contributed to the death of Ned O’Donnell

Before Senior Coroner for Liverpool and Wirral Mr Andre Rebello OBE
Liverpool Coroner’s Court
3 to 13 July 2017

The jury at the inquest of Edwin ‘Ned’ Lewis O'Donnell have concluded that his death was accidental, contributed to by neglect at HMP Liverpool. Ned was pronounced dead after being found with a ligature round his neck on 23 October 2016. He was 26 years old and had a difficult childhood, having been taken into care at the age of five and subjected to sexual abuse whilst in foster care.

In May last year an inquest on another death at the prison came to a similar conclusion. Since 2015 there have been 14 deaths at HMP Liverpool.

The jury concluded that Ned’s death was contributed to by neglect relating to the following issues:
• Ned was on hourly observations as part of an ACCT* opened on 21 October. On two occasions staff identified the need to increase Ned’s observations and informally did so but failed to communicate this with other staff.
• When utilising the ACCT document there were several failings including missed opportunities to call for an ACCT review or increase levels of observation, and a lack of understanding about thresholds for doing so. 
• Ned was seen by healthcare and referred for an emergency mental health review, but the prison did not act upon this referral which was a gross failure.

The jury also noted that the condition of cells Ned resided in whilst in segregation were not fit for purpose. Ned was detained on the segregation unit at the time of his death and been there for a month.  After formally complaining he was moved from one cell without running water, a flushing toilet, or light after 10 days, to another cell in which the light and cell bell did not work.

Ned was on hourly observations as part of the ACCT* process after he deliberately cut his ear with a razor on 21 October, in what seemed to be an attempt to draw attention to concerns about his health. In the early hours of the 23 October Ned told a prison officer that he was “going to kill himself” before the officers killed him.  Giving evidence, the officer described Ned as paranoid and explained how there had been a clear deterioration in his mental state. Staff informally increased his observation levels, but failed to document or effectively communicate this change with other staff or initiate an ACCT review.

A nurse came to see Ned in the early hours of 23 October and made an urgent referral to the day health care staff to ask for Ned to be seen by mental health staff that same day. This did not happen and Ned never received a full mental health assessment before his death. During the day Ned told a cell cleaner that he would be dead by 8pm. The cleaner told the senior officer on duty, but this officer failed to escalate this information which the jury concluded was a gross failure. At 6.15pm Ned was found unresponsive in his cell, hanging by a ligature. They jury found that it is more likely than not that Mr O’Donnell put himself in the position in which he was found but did not intend to end his life.

The coroner has issued a Report to Prevent Future Deaths (regulation 28) to the prison, raising concerns that in other cases important information in assessing risk could be missed if action is not taken to remedy issues with communication and assessment raised in this inquest.

Ned’s family said:
“The conclusion will never bring Ned back but we hope that the findings will mean changes are made that will save lives in the future.  We were appalled to hear about the circumstances in which Ned died and are grateful these have been been made public.   The family want to express their gratitude to the prisoners who attended the inquest as witnesses, to the jury for their conclusion and to their legal team.” 

Leanne Dunne of Broudie Jackson Canter who represent the family said:
“We are shocked to hear that yet again a prisoner has died following poor communication and documentation keeping in this prison.  The jury have been extremely thorough in their findings and we hope that Liverpool prison take these extremely seriously so that no further unnecessary deaths occur.  We hope that Ned’s family have managed to find some comfort in the inquest process and can begin to move forward following Ned’s tragic death.”

Anita Sharma, the family’s caseworker at INQUEST said:
“The litany of gross failures to respond to Ned’s fears, mental ill health and vulnerabilities resulted in the avoidable death of yet another young man.  This prison has been the subject of critical inspection reports and jury findings on a number of occasions.  Through our casework, we have seen similar failings across the prison estate with an ever-increasing number of self-inflicted deaths. We repeat our call on the Government to implement a national oversight mechanism to learn from previous deaths to prevent future deaths. There must be a demonstrable commitment to stem these avoidable deaths.”

ENDS

NOTES TO EDITORS

For further information, please contact Lucy McKay on lucymckay@inquest.org.uk or 020 7293 1111

The family is represented by INQUEST Lawyers Group members Leanne Dunne and Alice Stevens of Broudie Jackson Canter Solicitors and Ifeanyi Odogwu of Garden Court Chambers.

1. *ACCT= Assessment Care in Custody and Teamwork (ACCT) review, part of the suicide and self harm monitoring processes
2. Since 2015 there have been 14 deaths at HMP Liverpool.
3. HM Inspectorate of Prisons found the prison was not sufficiently good across all tests, including safety in an unannounced inspection.
4.  In May 2016 an inquest jury found neglect caused the death of 24 year old Lee Rushton at HMP Liverpool, in damning narrative conclusion. Full details can be found here.
5. To date, since 2015 there have been 14 deaths in HMP Liverpool, 6 of which were self inflicted and one of which is awaiting classification.

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