20 January 2017

An inquest jury today found that “neglect” contributed to the death of a young father who died in HMP Chelmsford after being taking into custody when he was in severe mental health crisis.

The jury found that Dean Saunders and his family were “let down by serious failings in both mental health care and the prison system” and said that Care UK, the private company that runs healthcare at the prison, “treated financial consideration as a significant reason to reduce the level of observations” of Dean, despite repeated warnings of his state of mind.

They concluded that Dean killed himself while the balance of his mind was disturbed and that the cause of death was “contributed to by neglect”.

Dean Saunders, 25, was found dead in the prison on 4 January 2016 after electrocuting himself. It was his first time in prison. Dean showed signs of acute mental ill health in the days before his imprisonment. He was taken from his home by the police on 16 December 2015 after an incident during which he tried to take his own life. At the police station, he was not detained under the Mental Health Act and transferred to hospital. Instead, he was charged and subsequently transferred to HMP & YOI Chelmsford (2).

The two-week inquest into his death before a jury and HM Senior Coroner for Essex, Caroline Beasley-Murray, which ended today, heard evidence from a number of individuals that when taking decisions about prisoners’ levels of observations, the Head of Healthcare took into account her budget and financial considerations – a claim strongly denied by her.

The inquest jury found that a number of serious failings led to Dean’s death, including:

  • Inadequate mental health assessments at Basildon Police Station and in HMP Chelmsford, where the results of the assessment were described as “predetermined” and medical or mental health professionals were not present.
  • The Head of Healthcare at the prison, an employee of Care UK, the private company in charge of healthcare, “treated financial consideration as a significant reason to reduce the level of observations” of Dean.
  • An “inadequate” response by HMP Chelmsford to the family and “multiple failings” in recording information pertinent to Dean’s situation.
  • An “absence of clinical leadership” in the healthcare wing of HMP Chelmsford.
  • A “total lack of consistency and logic regarding the level of risk ascribed to Dean’s situation” and “perfunctory” observations (full inquest conclusion in notes below).

The jury said it was unclear whether sufficient enquiries were made to find Dean a mental health bed out of the local area and said: “While we do not believe that the result of the assessment itself was predetermined, the pathway to prison was.” The first available bed following Dean’s arrest on 16 December 2015 was on 4 January 2016 – the day he died.

The jury said the inquest was an “extremely challenging case” and expressed their “sincere condolences” to Dean’s family.

Dean Saunders’ death was one of five self-inflicted deaths in HMP Chelmsford since 2015, including a prisoner who died on Christmas Day, 2016. Like Dean, that individual was on a suicide and self-harm management plan.

In a statement, Dean’s family said: “The jury’s damning indictment is not the end of our journey. It is the start of our mission to ensure that the changes we, and previous families, have been promised are embedded in real practical action and true accountability. This means a fundamental change in how mental illness is perceived and treated. Hospital, not prison, is where Dean deserved and needed to be. We as a family, together with our lawyers and INQUEST, want Dean’s death to mark the end of empty promises and the start of change.” (Full statement in Notes to editors)

Deborah Coles, Director of INQUEST, said: “Dean Saunders, a young father in serious mental health crisis, should never have been in prison in the first place. His death was entirely preventable. The responsibility for his death lies with a system that criminalises people for being mentally ill. As a society, we should not accept that deaths such as Dean's are inevitable: they are not. Time and again, we hear the empty words “Lessons will be learned”. Without action and accountability, nothing will change. Until this government properly invests in mental health provision, and stops the use of prison for people in mental health crisis, these tragic and needless deaths will continue.”

Charlotte Haworth Hird, Dean’s family’s solicitor, said: “Dean’s death was yet another example of the warnings of a loving family being ignored by professionals. There were repeated claims during the inquest that the healthcare wing at Chelmsford prison was a place of safety for Dean whilst he waited for transfer to hospital. The jury’s findings clearly show that it was not. There needs to be immediate action by the authorities to ensure that those in mental health crisis are diverted away from the criminal justice system and that essential mental health beds are available.”

INQUEST has been working with the family of Dean Saunders since January 2016.  The family is represented by INQUEST Lawyers Group members Charlotte Haworth Hird of Bindmans Solicitors and barrister Sean Horstead of Garden Court chambers.

For further information or to request an interview, please contact Laura Smith (media team – 07811 218 621) or Selen Cavcav (caseworker) on 0207 263 1111.



Notes to editors:

  1. Statement of Dean Saunders’ family following the verdict in full:

“We welcome the jury’s verdict which finally confirms what we have known all along. It is over a year since Dean’s death and in all that time we have yet to receive a formal apology from SEPT, Care UK or the prison.  We all consider that an absolute disgrace.

Over the 18 days that Dean was in prison, his health continued to deteriorate, he had no medication and he was unable to communicate with us, or us with him: the prison and healthcare's incompetence ensured that. It was the least he and we were entitled to expect, and even that was denied.

We are horrified that Dean spent those last days feeling abandoned by those who loved him to the point that, by the day before he died, he was cutting himself, speaking of a lethal injection to speed things up and wanting to talk to the chaplain to make a funeral plan. The health care staff knew of these events and did nothing in response to them to safeguard him.

If only the people responsible for keeping him safe had simply done their jobs, then Dean would be alive today with us and our beautiful baby boy. Instead, for the reasons identified by this jury, he was taken from us in the most horrific circumstances imaginable. Anyone with a child, a brother, a sister, a son, a daughter, a niece, a nephew, a mother, a father, please try and imagine what we have been through in hearing the details of Dean’s last days despite everything we did, or at least tried our very, very best to do. Dean could have been yours.

The independent investigation in advance of this inquest concluded that Dean’s death was both predictable and preventable. We agree and the one thing we add is it wasn’t only predictable, it was, in fact, predicted by us. We know, having been blind to this before Dean entered this dreadful system, that the easy words of regret and promises to change the system are nothing but that: empty words. We, like all the families that have gone before us up and down the country who have lost loved ones in preventable circumstances, hear those empty words and reject them. This cycle has to come to an end. Reviews have happened and recommendations have been made before but until those are actually put into practice and individuals are held accountable, then this will not stop.

We have heard that £10 million is to be shared between a number of prisons and from our bitter experience, we know you cannot put a price on a life; but what we can say is that given the scale of failings we have heard, £10 million is a drop in the ocean. Proper reform of how this country treats people with mental health issues means ensuring that those who need and deserve to be in hospital, rather than caged in a Victorian prison, whatever the financial cost, must be guaranteed.

This has got to come to an end.”


  1. 2016 saw the highest number of self inflicted prison deaths on record – a total of 113 deaths. http://inquest.org.uk/statistics/deaths-in-prison 
  2. Background to Dean Saunders’ death:
    1. Having suffered no mental ill health previously, Dean became unwell days before his imprisonment and showed signs of serious psychosis. He became paranoid and thought people were after him and his family.
    2. He was arrested following an incident when his brother was stabbed and his father, in an attempt to save Dean from self-harm, was also stabbed. When he was taken to Basildon Police Station on 17 December, a decision was made to detain him through the criminal justice system rather than transfer him to hospital under the Mental Health Act.
    3. On his arrival at HMP Chelmsford, there were serious inadequacies in the way his known risk of suicide and self harm was managed by the prison healthcare provider, Care UK. Staff failed to take the necessary steps to protect Dean, despite his expression of clear suicidal thoughts and serious attempts at self harm and his family’s attempts to alert the prison to his high risk of suicide.
    4. Days before his death, when his family found out that his observations were reduced from constant to every half hour, his mother warned the prison that Dean would take his life if he was not put back on constant watch.
  1. Care UK is the biggest provider of healthcare to the UK’s prison service. The provider took over healthcare provision at HMP Chelmsford in May 2012. A report published yesterday by the Independent Monitoring Board at HMP Chelmsford expressed concern at “increased” levels of violence, bullying and self-harm in the prison and described the physical and mental healthcare service provided by Care UK as “inadequate”. It also highlighted the provider’s difficulties with recruiting and retaining staff and its reliance on agency staff “to cover clinical vacancies”. It added: “In addition, the chronic shortage of secure mental health places available outside the prison, relative to the large numbers of prisoners with serious mental health problems, means that, in the Board’s view, the mental health provision for prisoners is far from adequate.
  1. Care UK has been criticised over several recent deaths in prison. An inquest into the death of Tedros Kahhsay in HMP Pentonville in January 2016 criticised Care UK staff over their chaotic response when he was discovered in his cell, including their apparent inability to perform basic CPR. A Prevention of Future Deaths (PFD) report issued after the death of Terence Adams, also in HMP Pentonville, in November 2015, identified “significant failures” by Care UK.

 6. Inquest conclusion in full:

  • “The mental health assessment at Basildon Police Station was not adequate due to a failure to pass information pertinent to Dean’s then mental state and its consequent risks; the delay in carrying out the assessment contributed to the serious failing.
  • While we do not believe that the result of the assessment itself was predetermined, the pathway to prison was.
  • On the balance of limited evidence and lack of proper audit trail, we are unable to conclude whether sufficient enquiries were made into the availability of beds out of area or privately. The only certainty is that a bed at Brockfield House was only available on 4 January 2016 (the day Dean was found dead).
  • It was clear Dean was in need of a place of safety. As such, his route from Basildon Police Station to prison was the only option.
  • In our view, the assessment on 21 December 2015 was not adequately conducted for the following reasons:
    • No medical or mental health professional attended the assessment
    • The assessment did not have sufficient multidisciplinary attendance
    • The Head of Healthcare had to a very large extent predetermined that the result of the assessment would be the removal of constant watch
    • The Head of Healthcare treated financial consideration as a significant reason to reduce the level of observations
    • The attendees of the assessment failed to review sufficient background information prior to the assessment including full and detailed knowledge of key events such as the plastic bag incident which had taken place moments before the ACCT Review.
    • The assessment was held prior to the completion of the psychiatrist’s assessment.
    • HMP Chelmsford’s response to the family in general and on 23 December 2015 in particular was inadequate. These include but are not limited to basic administration errors, such as failure to record and pass on telephone numbers, failure to record all information, failure to initiate usage of the phone PIN system and no consideration of family attendance at ACCT assessments which we feel would have been appropriate in the circumstances.
    • At HMP Chelmsford there were multiple failings in recording and communicating pertinent information relating to Dean’s circumstances. These included but are not limited to: discrepancies between various official records, failure to provide full explanations in recorded entries, failure to record key incidents.
    • There was an absence of clinical leadership in the healthcare wing of HMP Chelmsford. There was confusion regarding the Head of Healthcare’s qualifications amongst members of staff.
    • The administration and performance of ACCT reviews was wholly inconsistent and record keeping incomplete. Such as confirming a case manager throughout the ACCT, confirming risk level on 24 December and other information that must be completed in every case.
    • Finally, there was a total lack of consistency and logic regarding the level of risk ascribed to Dean’s situation and consequent levels of observation.
    • On 4 January 2016 the performance of observations was perfunctory as the member of staff did not engage with Dean as required in the PSI and checks were not carried out on an irregular basis.
    • There was a failure to transfer Dean to a medical facility as the Section 48 process in operation at HMP Chelmsford is contrary to industry best practice.
    • In addition, the psychiatric assessment on 21 December failed to take into account the fact that Dean’s observation levels had been reduced at the ACCT meeting earlier that day.
    • In summary, Dean Saunders and his family were let down by serious failings in both mental health care and the prison system.”

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.