Liam Ryan Wayne Bentley · Prevention of Future Deaths report

On 13th June 2022 I commenced an investigation into the death of Liam Ryan Wayne Bentley. The investigation concluded at the end of the inquest on 29th June 2023. The conclusion of the inquest was Liam Bentley took his own life (████████) but his intention in doing so was unclear. The failure to provide adequate physiological support through SOS and/or a psychologist possibly contributed to the death. Other issues which were deemed to be relevant to the circumstances of the death but could not possibly contribute to the death were as follows. 1. Failure to open an ACCT on or after 16th April. 2. Failure to instigate a care plan 3. Inadequate response to missed medication from 16th April onwards. 4. The Management of the self exclusion plan was inadequate, and failures to implement agreed actions from CSIP and SIM meetings. 5. Ineffective communication between the prison and the health care provider. 6. Staff shortages and gaps in training.

Liam Bentley was transferred to HMP Swaleside on 25th March 2022. He was a serving prisoner with a sentence expiry in 2024. He had ADHD and ASD for which he was medicated with mirtazapine administered by healthcare and at the time of his death atomoxetine, held in possession. He had 19 previous ACCTs for self harm and an attempt at suspension whilst serving his sentence at other establishments. Following his transfer he informed prison staff that he was in fear of other prisoners and wanted a move to another wing. He caused a superficial cut to his hand and said that he wanted to kill himself before anyone else did. An ACCT was not opened, the evidence being that officers after further speaking to him did not regard this as a self harm issue, the focus being to engineer a wing move. He was moved to a different wing but continued to express concerns about prisoners on the new wing. A self exclusion document was opened, a local policy closely aligned to the ACCT process aimed at reintegrating the prisoner to the regime was started but was not managed in accordance with the policy with assessments and reviews being done weeks after they should have been and no management plan were not put in place. Required daily interactions were sometimes done, sometimes not, referrals to psychology and SOS were either not made having been identified as necessary through the self exclusion, CSIP and SIM processes or made and not actioned

(1) There was evidence from prison staff from which it was concluded by the jury that the safety of deceased was compromised as a result in staff shortages
(2) The current complement of Band 2 Operational Support Group staff is 71% this is predicted to further reduce to 54%, the current complement of Band 3 Prison Officers is 68% this is predicted to further reduce to 46%.