James Devenny · Prevention of Future Deaths report

James Devenny died on 2 September 2019 at HMP Elmley, aged 34 years. An investigation into his death was commenced. The investigation concluded at the end of the inquest on 18 May 2021. The jury found that the medical cause of Mr Devenny’s death was hanging. Their conclusion was that he died of an accidental death and there was a failure to open an ACCT document which caused or contributed to his death. The jury also found a series of factors possibly contributed, as explained further under section 4 below.

James Devenny died in his single occupancy cell on House Block 2 in HMP Elmley at some point between 1433 and 1558 on 2 September 2019 when he was found, hanging from a light fitting in his cell using a ligature made from a bedsheet.

Prior to his death Mr Devenny had been isolated in his cell due to a concern that he posed a risk of violence. The jury found that Mr Devenny's Death was possibly contributed to by the following factors:

(1) Staff on houseblock 2 at HMP Elmley were not aware of information as to his history of self-harm which occurred before he arrived there.

(2) Following the decision to keep Mr Devenny separated from other prisoners, there was not an assessment by a medical professional as to whether he was fit to be separated.

(3) The response of the mental health in reach team to referrals in respect of Mr Devenny was not appropriate.

In addition, the jury noted in their narrative that:

(1) We feel that lack of access to a phone in cells, to contact support services was inadequate

(1) In the absence of telephones which are installed directly into the cell, there is no direct means for a prisoner to contact the Samaritans. In the event that a prisoner does not have access to a telephone they are reliant on staff to convey them to a telephone so they may call. There is a particular difficulty in respect of prisoners who are deemed to pose a risk of violence and who may not be able to immediately access a telephone, a listener or a member of Chaplaincy.
(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT. Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm.