Callum was a 25-year-old young man with two children.  He had a history of mental health problems. Whilst in HMP Highpoint, he was placed under suicide and self- harm management programme after he told a prison psychologist of an attempt to take his own life while at HMP Highpoint in October 2012.  Three days later he was deemed no longer at risk of suicide.  He was then referred for a mental health assessment and was seen by a mental health nurse and prescribed anti-depressants.  However, when his nurse left the prison in November 2012, he had no further contact with mental health professionals.  Up until his death, Callum tried desperately to make an appointment with mental health team.  When he was found hanging in his cell by another prisoner on 8 April 2013 an application form for a mental health appointment was found. However no appointment had been arranged.
The jury found that Callum received no notification of any mental health appointments after his contact with his mental health nurse ceased in November 2012 and that this has contributed to his death. They also found that his anti-depressant medication was not monitored after this death.

The jury also recorded the following:

“Whether through possible failings in the appointment notification process, decisions that Callum may have taken not to attend an appointment or for any other reason that might have resulted in the lack of face to face mental healthcare contact, we find it more likely than not that the lack of face to face mental healthcare contact after 22 November 2012 contributed more than minimally, negligibly or trivially to the death”

Callum’s mother Helen Carey said:

"Callum was a loving young man. He was helpful and brought joy to the lives of his family and friends. He is sadly missed by many, particularly his children. Since I learnt of his death, I knew that there was something wrong and have always felt strongly that his death was avoidable. The jury’s findings that failings in mental health services contributed to his death reflects what I believe went wrong. I am grateful to the jury and would like to thank them for being so engaged. It means a lot to me. I would also like to thank INQUEST who have supported me from the beginning and also my legal team for all their hard work. “

Sara Lomri, family solicitor said:

“Callum’s inquest heard evidence of individual and systemic failings surrounding his death, particularly in mental health care. The jury concluded that failings in that care contributed to his tragic death. Sadly, I am representing the families of numerous young men who died at HMP Highpoint in 2013 and 2014. The evidence seen by the families indicates that although repeated assurances were made regarding improvements in mental health services and suicide prevention plans over that period, failings arose time and again, which are linked to the deaths. Helen has been heartbroken to learn that although the prison service, Norfolk and Suffolk Foundation Trust and Care UK all said that lessons were learnt after Callum’s death, there were subsequent deaths of other vulnerable young men at HMP Highpoint involving failings mental health and suicide prevention failings. Together with INQUEST, the legal team will be looking carefully at how systems at HMP Highpoint have been developed over the past three years and address HM Coroner as to how deaths might be avoided in the future.”

Deborah Coles, Co-Director of INQUEST said:

“Callum did not slip through the net.  He was asking for help and was not given it. He was clearly vulnerable and desperate to speak to someone face to face about the problems he was facing.  How many other people are sitting in their cells desperately crying out for help in prisons which are not equipped to deal with vulnerable people with mental health problems. The fact that 3 other men were found hanging in the same prison after Callum’s death should alarm everybody whose job it is to make sure that our prisons are safe.”
 

INQUEST has been working with the family of Callum Brown since 2014. The family is represented by INQUEST Lawyers Group member Sara Lomri from Bindmans solicitors and Ruth Brander from Doughty Street Chambers.

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