20 November 2020

Before HM Area Coroner, Yvonne Blake
Norwich Coroner's Court
11 - 20 November 2020

David Sparrow, 36, was found hanging in his cell in HMP Norwich on 4 June 2019 and died in hospital the following day. The inquest into his death has concluded with the jury identifying a series of failings contributed to his death including that:

  • Available information about David's mental health was not acted upon.
  • His antipsychotic medication was missed.
  • There were insufficient staff on duty on the night that he died.
  • There was a lack of comprehensive handover of information before the night shift.
  • There was a failure to follow prison policy regarding the need to enter cells as soon as possible when an observation panel has been blocked.

David was a much loved son, brother and partner who was described at the inquest as a lovely, caring person with a very kind heart. He had a particular interest in movies and he had aspirations to go to college. Upon release he was looking forward to moving in with his partner and accepting a job offer as a roofer, installing solar panels.
David had been recalled to prison on 18 May 2019. David had a history of serious mental ill health. He had diagnoses of psychosis and a personality disorder for which he was prescribed anti-psychotics, and had previously been an inpatient in a mental health hospital. Prior to being recalled, he was under the care of the community mental health team. However, the inquest heard that this information was missed by the prison mental health clinical team leader when conducting a desktop assessment and David was not brought under the care of the mental health team in prison, which he accepted to be a mistake.
Evidence was heard that between 29 May and 4 June, David told prison staff multiple times that he was scared and under threat because other prisoners incorrectly believed he was a ‘sex offender’. He had no history of sexual offending and there was no evidence for such threats. However, this was a known presentation of his paranoia which was a symptom of his schizophrenia. On two occasions his probation officer contacted prison officers with this information but the inquest heard this was not passed on.
David began to behave increasingly bizarrely and was self-isolating in his cell because of fear of prisoners and staff. As he was self-isolating, he was discussed at a Safety Intervention Meeting on 4 June. Evidence was heard that the clinical team leader for mental health did not check their records in advance of the meeting and as such failed to recognise that he had an ongoing mental health condition, had previously been referred to the mental health team, and that his self-isolating was because of his schizophrenia.
On 18, 19, 20, 28 May and 2, 3 and 4 June there is no evidence that he was administered his anti-psychotic medication. Upon receiving letters from David, his partner became increasingly worried and called the prison 18 times over the two weeks prior to his death to express her concerns. Only two of these calls were logged, and only twice did she speak to a prison officer. On other occasions she was told that she would be called back and was not. At the inquest a nurse stated that had David been part of the mental health team’s casework, missed medication would have been flagged up with them.
David was then moved to another wing on 4 June on the mistaken understanding that the threats he described were based in reality. It was not until David self-harmed that afternoon that he was put under suicide and self-harm monitoring processes (known as an ACCT) and the mental health team saw him for the first time. At 11.24pm that evening, whilst conducting an ACCT check, night staff discovered his observation panel was blocked and David did not respond from behind the door.
Prison policy states that officers should enter a cell as soon as possible when an observation panel is blocked, particularly when the prisoner is on an ACCT. Despite this, the inquest heard that there was a 30-minute delay in staff entering David’s cell. This delay was partly caused by prison staff, for no apparent reason, failing to use their personal radios and instead walking to an office to use a telephone. Prison staff also failed to realise that they had a key on their person, and that at the time there was only one staff member responsible for 170 prisoners. Upon finally entering the cell, they discovered David hanging. He died the following day in hospital.
Robert Sparrow (father of David), Lisa Sparrow (sister of David) and Sharon Harrowing (partner of David) said: “David must have felt terrified and hopeless to have taken his own life but it did not need to end this way and, had he been properly cared for, it seems that he would still be here with us.
The failings of prison and healthcare staff were clear during the inquest. All we have wanted is justice for David and we are glad that, for David's sake, the jury recognised the failings too. We hope that changes will be now made because we would not wish what we have gone through to happen to any other family.’"
Bola Awogboro, Caseworker at INQUEST said: “This inquest has exposed a litany of failures by HMP Norwich which led to David’s death. The signs of David’s distress could not be clearer, and was highlighted to the prison time and time again by his partner, only to be ignored. People in prison and their families have no choice but to entrust prison staff to fulfil their duty of care, while the mechanisms for doing so frequently fall short of what is required.
Prisons are inherently dangerous environments, ill-equipped to protect people from harm. Effective change can only come from a dramatic reduction in the prison population, and investment in diversion and community alternatives.”
Aston Luff of Hodge Jones and Allen Solicitors, who represents the family, said: “The circumstances that led to David's death are shocking. This was an extremely vulnerable man whose mental health deteriorated into extreme paranoia under the strains of prison life. The prison had all the information they needed to recognise his vulnerability and care for him appropriately and yet his needs were missed over and over again. A huge proportion of the prison population are extremely vulnerable, both to mental health challenges and to the system they find themselves in. We hope that this is a stark reminder that prisoners need to be cared for, not just locked up. Otherwise the consequences can be devastating.”



For further information, please contact Sarah Uncles on 020 7263 1111 or [email protected]  A photo of David is available here.

INQUEST has been working with the family of David. The family is represented by INQUEST Lawyers Group Aston Luff of Hodge Jones and Allen Solicitors and Katy Thorne QC of Doughty Street Chambers.

The other Interested Persons represented at the inquest are the Ministry of Justice, Norfolk and Suffolk NHS Foundation Trust and Virgin Care.