Issues with record keeping and sharing information at HMP Durham could have contributed to the death of an inmate, an inquest heard.
Garry Beadle, 36, from Newcastle, was transferred from the prison to hospital, where he died on February 11, 2019.
The father-of-five was in custody on remand and had only been in the prison for six days. His death was ruled as suicide.
An inquest at Durham and Darlington Coroner’s Court heard it was Mr Beadle’s first time in prison.
He arrived at HMP Durham on February 1 with a suicide and self-harm warning form, known as a SASH.
It recorded that Mr Beadle had attempted to take his own life in the last two weeks.
The form also recorded Mr Beadle’s repeated statements that he had mental ill health issues, the court heard.
On reception at HMP Durham, a senior prison officer discussed the SASH form with Mr Beadle.
He told officers he felt so down he would attempt to take his life again, and he missed his children “like crazy”, the court was told.
But, the officer did not fully record this, which he accepted at the inquest was a missed opportunity for sharing information.
Mr Beadle also had additional risk factors including being a remand prisoner, it being his first time in custody, his diagnosis of depression for which he received medication in the community and a recent breakdown of a relationship, the court heard.
On the afternoon of February 3, the jury heard that Mr Beadle had telephoned a close friend. The friend was extremely concerned and felt Mr Beadle was saying goodbye.
Mr Beadle asked his friend to look after his children and said “I have everything I need now to do what I am going to do.”
The friend contacted Northumbria Police about his concerns, who then spoke to the prison.
HMP Durham recorded the police contact in security intelligence records, which healthcare staff and most prison officers do not have access to.
The information was not passed on to mental health staff or anyone involved in the ACCT reviews, the court heard.
Witnesses confirmed they would have expected a record of this call to appear on the ACCT document. One officer said, had it been recorded, they would have considered raising Mr Beadle’s risk to high.
A senior nurse manager at Tear Esk and Wear Valley NHS Foundation Trust, who provide mental health services in HMP Durham agreed that this was a missed opportunity for important information about Mr Beadle’s risk to himself to be shared.
The Governor of HMP Durham told the jury that there is no evidence that the security intelligence record was passed to the Safer Custody department, or to a Governor to review, as it should have been.
On the morning of February 7, a scheduled ACCT review took place, attended by a custodial manager and a mental health nurse. Based on Mr Beadle’s presentation, his level of risk of harm to himself was reduced from ‘raised’ to ‘low’.
This was despite an incident the evening before where Mr Beadle had been distressed about a change in his cellmate, and was left as the single occupant in his cell.
The custodial manager was still not aware of Mr Beadle’s phone call to his friend, and accepted that as a result the risk assessment was inadequate. Had they known, they would have considered his risk to be high.
His mum Karen Beadle said: "As Garry's mum, I truly feel many of us have lost a very special person.
“A joker, prankster, loved being with his friends and his passion for football never faltered, a talent he excelled in.
“After all the evidence from the inquest has come to light, it is crystal clear that Garry was overwhelmed, confused, emotional and that more attention should have been paid to the red flags that Garry was waving for help and support.
“We now know that fundamental errors were made in Garry's short time at HMP Durham.
“We must do more to protect people in these positions, as I do not want any other families to go through what I have and am."
Tara Mulcair, solicitor at Birnberg Peirce who represented the family, said: “It is vital that HMP Durham and the Ministry of Justice ensure that lessons are learned so that the failings in Garry’s case are not repeated in the future.”
A Prison Service spokeswoman said: “Our condolences remain with Mr Beadle’s family and friends.
“Lessons have been learnt at HMP Durham with improved training for staff, a 24-hour helpline for concerned loved ones and better record keeping so vulnerable prisoners can be identified and supported.”