Isabel Bertschinger represented NF’s family at inquest. NF was imprisoned at “offence neutral” HMP Fosse Way in 2024. He took his own life seven months into his time at the Leicester prison, which is operated by Serco and opened in May 2023.

The jury found that bullying, verbal and physical abuse were common throughout the prison. They found that NF experienced all three of these, that he frequently reported such incidents to the prison, and that staff were aware of the incidents and the impact on him. The jury found that some of the reported incidents were not investigated thoroughly due to a lack of supporting CCTV. NF was assaulted in March 2024 by another prisoner who threw a kettle of boiling water at him. The jury found that a thorough assessment to establish the extent of his injuries was not carried out and the incident was not reported to the police. NF felt unsafe at HMP Fosse Way and made this clear to staff.

The jury found that the majority of the staff were inexperienced, and that it was common for shifts to start without the required number of staff, with more senior prison officers spending much of their time trying to find cover.

NF was placed on an ACCT for a period of time during the summer of 2024. The jury also found that the term ‘multi-disciplinary team’ was not defined which adversely affected the ACCT process. Serco admitted that a Custodial Operations Manager (COM), failed to properly document ACCT reviews within the ACCT document.

The jury found that the ACCT post-closure process was not followed correctly. They identified a missed opportunity within the post-closure process to fully consider whether the ACCT should have been re-opened.

Communication was also criticised by the jury, who found that there were deficiencies in information sharing and teamwork between prison and healthcare staff. They made reference within their conclusion to a message NF sent to his Offender Manager on 21 September 2024, in which NF stated he was losing the will to live. This message was not seen as the OMU is not manned at the weekend. The jury found it is probable that a further ACCT would have been opened immediately if this message had been seen before NF’s death.

Finally, the jury noted that NF was impacted by long waiting lists for courses required to transfer to a Category D prison. NF believed that he would have to move wings to access one such course and feared he would be in danger of further assaults. The jury found that prison staff did not correct his misunderstanding or allay his fears.

Serco admitted that a Prison Custody Officer (PCO) failed to undertake welfare checks at 22.00 and 06.00, prior to NF being found ligatured at 07.33 on 23 September 2024.

The prison has since changed so that 700 prisoners are housed separately to the main population. However, education and other activities are still mixed so there is no traditional “VP wing”. HM Coroner is expected to issue a PFD on the issue of offence neutral prisons.