Lack of mental health care contributed to death of ‘highly regarded’ prisoner

A Prison Officer at walking past the gates of HMP Highpoint Prison in Suffolk

A Prison Officer at walking past the gates of HMP Highpoint Prison in Suffolk - Credit: Eastern Daily Press, Archant

A prisoner who was “highly-regarded” by staff and fellow inmates should have received more face-to-face mental health care before his death, a jury has concluded.

Callum Brown, 25, originally from Romford, was found dead in his cell by fellow inmates at HMP Highpoint South, near Bury St Edmunds, Suffolk, on April 8, 2013.

Today, a jury concluded that after Mr Brown’s mental health care worker James Allison left in November, 2012, he did not attend any further appointments, despite still taking prescribed antidepressants.

“Whether through possible failings in the appointment notification processing, decisions that Callum may have taken not to attend an appointment, or for any other reason that might have resulted in the lack of face-to-face mental health care contact, we find it more likely than not that the lack of face-to-face contact after November 22, 2012, contributed more than minimally, negligibly or trivially to his death,” said the 11-strong jury at the inquest.

The jury concluded it was “more likely than not” Callum had not received notifications of his appointments.

During this time, the mental health care at the prison was provided by the Norfolk and Suffolk NHS Mental Health Trust, which subcontracted the service from Care UK.

The jury also said it did not feel the care team’s response to the missed appointments had been “adequate” and added it was also “more likely than not” this played a part in his death.

Most Read

However they concluded in the time leading up to his death Mr Brown was not showing signs he was at risk of self harm or of ending his life. They did say some family news that he received in early April, 2013, that upset him may have contributed to his death.

Despite finding Mr Brown had died from hanging, the jury did not return a suicide conclusion as it could not be proved that Mr Brown intended to end his life.

Coroner Peter Dean said of Mr Brown: “He was clearly a highly-regarded prisoner despite his personal troubles.”

He said there were three key factors the inquest had thrown up since it started on January 11.

Firstly, he highlighted the fact that prison staff compliance with requirements for welfare checks had not been sufficient. The inquest heard an overnight welfare check on prisoners had not been carried out the night Mr Brown died.

Secondly, the review process after a prisoner came off an ACCT treatment plan (assessment, care in custody, and teamwork).

Finally, Dr Dean questioned the adequacy of the system in place to follow up missed appointments.

Dr Dean emphasised it was clear the first two had not been contributing factors to Mr Brown’s death and added steps had since been taken to address these problems.