Before HM Senior Coroner Dr Peter Dean,
Suffolk Coroner’s Court

31 August 2016

The inquest into the death of David Smith concluded today with the jury finding a multitude of failures by HMP Highpoint.

David died at HMP Highpoint, aged 38, following an incident of serious self-harm on 23 May 2014. David was a vulnerable prisoner who had been sentenced to three and a half years in prison on 14 May 2014. He had a long standing history of anxiety, depression and self-harm. He was transferred from HMP Chelmsford to HMP Highpoint on 23 May 2014. Later that evening he hanged himself from a ligature in his cell and died the following day in hospital.

The jury found that the following failures were contributory factors in David’s death:

  • lack of training of prison officers
    • insufficient staff on duty
    • lack of awareness of protocols by prison staff
    • failure to follow protocols to check logs and wing books
    • lack of compassion for prisoners
    • failure to open earlier a suicide and self-harm procedure (Assessment, Care in Custody and Teamwork (ACCT) );
    • failure to properly complete and implement the ACCT when opened.

    Julie, Tony, Adam and Wayne David’s parents and brothers said:

“David should be with us today. Our son was calling out for help, but no one helped him and he should not be dead. If they had done their job he would still be here today.

We’d like to thank the jury for their hard work and being for our family.

We got the justice that David deserved.

Thank you to Sara, Anna and Sam, our brilliant team at Bindmans. Also thank you to Jesse, Tamiour and INQUEST for their help.

David will be deeply missed”

Deborah Coles, INQUEST Director said:

“This jury finding encapsulates the crisis within our prison system.  This is yet another jury finding of failures at HMP Highpoint relating to the death of a vulnerable prisoner with unmet mental health needs. HMP Highpoint is not learning from its own failures or improving the care and support provided to prisoners. The failures identified by this inquest must be responded to by the Prisons Minister Sam Gyimah”.

Sara Lomri, family solicitor

“The inquest into David’s death uncovered multiple failings on the part of HMP Highpoint.  The jury heard evidence from a range of sources and concluded that, in addition to failures of staff planning and training, those charged with the care of David lacked a basic level of compassion.

This inquest was the third of four linked inquests arising out of cluster of self-inflicted deaths of young men at HMP Highpoint in 2013/2014.  It is vital that lessons are learned by the management of the prison and steps are taken to ensure that the failings identified by David’s inquest and by those of the other three prisoners are comprehensively addressed to ensure that further deaths can be avoided.”

INQUEST has been working with the family of David Shane Smith since 2014. The family is represented by INQUEST Lawyers Group members Anna Thwaites and Sara Lomri from Bindmans LLP and Counsel Taimour Lay from Garden Court Chambers.


Notes to editors:

David’s death was the third of four self-inflicted deaths within a short period at HMP Highpoint.

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Source: INQUEST Casework and monitoring

The inquest for Callum Brown concluded in January 2016 for more information see here, the inquest for Steven Trudgill concluded in May 2016 for more information see here.

HMP Highpoint latest inspectorate report is available here.

For further information, please contact: Shona Crallan at [email protected].

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.