Adrian Johnson · Prevention of Future Deaths report

By a majority, the jury found that Mr Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13th May 2010 in the Segregation Unit of HMP Belmarsh.

1. Circumstances related to initial screenings in the First Night Centre:

The jury concluded that Mr Johnson died in part from serious failures within the prison system. His initial screenings within the First Night Centre failed to highlight the urgent need for a mental health assessment and did not ensure his medication needs would be met and failed to take appropriate heed of Adrian Johnson’s exceptional dependency on nicotine, the single trigger recorded on the already open ACCT.

2. Circumstances related to ACCT Reviews:

The jury found that the ACCT Review on the morning of 13th May 2010 was inadequately conducted, in the absence of clinical records, with no appropriate psychologist present as per HMP Belmarsh Suicide Prevention Policy and the omission of the solicitor’s letter from the family, received into Health Care Unit on the 12th May 2010. The reduction in the level of observations and relocation to a non-gated cell prior to securing the overdue mental health assessment amounted to neglect. On the balance of probabilities the ACCT Review failed to maintain adequate protection for a highly vulnerable inmate with a history of recent impulsive self harm (Two out of ten jurors objected to the use of the term impulsive in the absence of any mental health assessment being conducted).

(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.

(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners