Jonathan David Palmer · Prevention of Future Deaths report

On 30 November 2015 an investigation was commenced into the death of Jonathan David Palmer ('Mr Palmer'). On 18 May 2017 I concluded the investigation at the end of an 8 day Inquest, sitting with a jury. The Jury returned a Narrative conclusion.

On 3 June 2015 Mr Palmer was brought to HMP Wandsworth on remand prior to a trial which was listed to commence on 23 November 2015. On 19 November 2015 at approximately 1400 hours Mr Palmer’s lifeless body was discovered suspended from a ligature in his cell. He was declared dead at 14.58 hours, after resuscitation efforts were abandoned. The Inquest found the cause of death to be 1a Hanging.

In the period between June and November 2015 Mr Palmer had exhibited bizarre and violent behaviour. The prison and medical staff attributed his behaviour to the effects of an illicit drug, Spice. Mr Palmer’s family (including his two brothers who were also held on remand and shared a cell with him for part of the time) were convinced that he was experiencing a developing psychotic illness in addition to his pre-existing psychiatric conditions. The Narrative conclusion returned by the jury did not make a finding on the balance of probability as to whether his behaviour prior to his death should be ascribed to the misuse of illicit drugs, an emerging psychotic illness or a combination of the two.

Mr Palmer's community GP records were not obtained and hence those responsible for his assessment and treatment in the prison from June 2015 onwards, had little information available as regards his previous medical history. Relevant aspects would have included his suicidal ideation in earlier years and the diagnosis of a major depressive illness, approximately four months before he was remanded in prison.

Mr Palmer's family gave evidence that they endeavoured to make the prison aware of their concerns about his mental health in numerous telephone calls to safer custody, RAPT and those on chaplains, as well as posting documents to the prison cover, but the records available from chaplains and others did not enable the Inquest to determine the date, nature and value of all of the information alleged to have been sent to the prison.

Evidence taken at the Inquest indicated that Mr Palmer admitted at various times to having smoked Spice. The Jury did not, however, find any causal link between any illicit drug usage and the death.

One prisoner asserted in the course of his evidence that contraband material is smuggled into the prison by corrupt individuals, but the investigation of this matter was outside the scope of the Inquest.

1. There is no effective system by which the family of a prisoner can input information they deem relevant to a prisoner's health needs and be assured this will be disseminated to relevant teams within the prison, with appropriate records being maintained in order to be able to demonstrate this has been done.

Families can be a source of valuable medical information, particularly, where GP records have not been obtained and the individual himself may not be a reliable source. It would be beneficial to have a clear, publicised conduit for a family to provide relevant medical information to a specified department. The Inquest was informed that a single point of contact has now been established, but it remains unclear whether comprehensive records of all contacts will be maintained, or whether this will result in the timely dissemination of information to those with a role in the prisoner's welfare, such as healthcare staff, RAPt or the chaplains. As the Personal Officer scheme appears to have been abandoned at HMP Wandsworth there is no alternative individual for a concerned family to approach.

2. The steps taken to control the inflow of contraband material into the prison (such as the illicit drug known as Spice), appear ineffective.

Insidious substances such as Spice can mimic the symptoms of psychotic illness and jeopardise life when unpredictable reactions occur to those using it. Spice is also likely to adversely affect discipline within the prison, create the potential for intra prisoner bullying (arising from drug debts) and stretch already depleted healthcare resources. In order to combat this menace, steps should be taken to identify the entry points in order that they can be more effectively controlled and those involved, deterred.