Following an inquest held by HMSC King at East Sussex Coroner’s Court, a jury concluded that the deceased died by suicide and found that the circumstances that led to the death included “insufficient access to and management of mental health services”, and “a lack of information between prison staff in relation to potential risk” at HMP Lewes.

The jury found that (among other factors), the following contributed or led to the deceased’s death:

• The deceased’s relationship with inmates (including a prison debt)
• Reports to the deceased’s mother regarding his safety stating that a bounty of £3000 had been placed on him
• The deceased’s request not to be moved to another wing had been decline
• The deceased’s request for medication had been refused
• The length of time the deceased was waiting for a mental health review

The inquest heard of widespread changes that have been made to practices within the prison healthcare to improve information sharing, training ensure a trauma informed approach to mental healthcare, and clinical supervision of healthcare staff. Similarly, HMP Lewes has implemented system changes, including the creation of “safety and security” representatives on the wings to ensure improved information sharing, and the requirement for ‘handovers’ to take place upon every wing move.

Angelina was instructed by Alice Helm at Irwin Mitchell solicitors.