Major safeguarding reforms have been brought in to a Lancashire prison after a troubled inmate took his own life following an unlawful period of isolation without vital medication, exercise or showers.
On November 22, 2018, HMP Garth inmate Andrew Patrick Jones died by suicide after he was unlawfully held in an isolated cell for more than 24 hours.
Andrew had been placed in isolation due to an incident the day before. The incident concerned only himself.
During isolation, the vulnerable 37-year-old had his prescriptions for the mood stabilisation drug Quetiapine, as well as opiates through Tramadol to help with severe back pain, removed.
In total, he missed three separate medication doses over a 48 hour period.
Andrew also received no shower access, exercise, or telephone calls.
Dr James Adeley, Senior Coroner for Lancashire and Blackburn with Darwen, found that Andrew was "unlawfully segregated" and there was "no legitimate reason" to segregate him prior to a hearing into the incident that took place the day before his death.
Dr Adeley also found no evidence of Andrew ever being assigned a Personal Officer, whose job would have been to gain a greater knowledge of Andrew through regular interaction. There was also no evidence of attempts to explore Andrew's behavioural issues, relating to increasing paranoia and back pain.
Senior prison staff admitted the segregation was illegal and that Andrew should have been returned to his prison wing at the end of a de facto four-hour period; the legal time period prisoners can be held in isolation for prior to hearings.
Ultimately, the jury at Andrew's inquest found that there was a 'gross failure to provide even basic care for a fully dependent person', adding that 'every opportunity to provide this care was missed'.
The jury concluded by saying Andrew's death 'was contributed to by gross neglect'.
Following his inquest, LancsLive can now reveal that major changes have taken place at HMP Garth to improve safeguarding policy for vulnerable prisoners.
There has also been changes to the general segregation procedure at the Lancashire prison, near Leyland.
The illegal use of segregation had been "routine practice" under rules which had been brought in at HMP Garth some three to four years prior to Andrew's death. During that time, an estimated 600 to 700 prisoners were isolated beyond the de facto four hour period allowed under segregation laws.
Since Andrew's death and inquest, HM Prison and Probation Service told LancsLive that "robust action" has taken place including "specialist staff training, dedicated support for each prisoner and new guidance on both segregation and safe movement of prisoners".
Now, all HMP Garth prison officers are required to undertake training on suicide and self-harm prevention.
Since Andrew's death, a 'key worker scheme' has been introduced at the prison. This means that each prisoner now has support from a dedicated prison officer.
Prison governor, Steve Pearson, has also committed to conducting a joint review with Greater Manchester Mental Health - the healthcare provider at HMP Garth - to ensure that a consistent approach to dispensing medication is being followed across all areas of the prison.
A HM Prison and Probation Service spokesperson added: "This was a tragic incident and our condolences remain with the family and friends of Mr Jones."