Media Media releases Dominic Noble inquest: Coroner highlights ‘meagre’ mental healthcare provision at HMP Leeds 19 August 2022Before HM Senior Coroner Kevin McLoughlinWakefield Coroner’s Court 27-30 June 2022Dominic Noble, 32, died by suicide in HMP Leeds on 15 August 2020. He was awaiting trial after being charged with left wing terror offences whilst experiencing serious mental ill health. Following a mental health assessment, Dominic was waiting to see a psychiatrist but died before ever being offered an appointment.Dominic’s family are now speaking out about the poor care provided at the prison and their frustration with the recent inquest. Despite concerning evidence, the inquest on 30 June 2022 made uncritical findings on the management and treatment of Dominic by staff and mental healthcare professionals within the prison. However, the coroner will now be issuing a report to prevent future deaths on the “meagre provision of psychiatric consultant availability” from the prison healthcare providers Practice Plus Group (PPG - formerly Care UK).Since 2015 there have been 65 deaths of men at HMP Leeds, of which 26 were reported to be self-inflicted. The most recent prison inspection in September 2019, a year before Dominic’s death, found levels of self-harm were significantly higher than other local prisons and the management of suicide and self-harm procedures (known as ACCT) was not good enough.BACKGROUNDDominic’s mother described him as, “A highly intelligent young man who had struggled with depression for a considerable time, he cared about injustice and was always prepared to help people when he could. He was a much loved son. He was an avid researcher of all things and he wasn’t a terrorist!” Dominic was remanded into custody at Leeds Magistrates Court on 8 June 2020 and was taken to Leeds prison for the next 10 weeks awaiting trial. On Saturday 15 August 2020 at approximately 2pm, Dominic was discovered ligatured in his cell. A paramedic attended and he was pronounced death at 2:26pm.Dominic’s mental health had been deteriorating since 2019 following a series of issues including his tax credits being stopped. He became increasingly frantic about political and social causes, which led to him becoming more isolated from friends and family. He became suicidal and his family became increasingly worried.On 2 June 2020, the police were called to an address because Dominic had broken a TV. Dominic was Tasered and conveyed to police custody, where he made a comment about blowing up a police car. This triggered a counter terror response under PREVENT policy, and his electronic devices were seized and analysed. Dominic was arrested and charged with left wing terrorist offences on 2 June 2020 and remanded to HMP Leeds. EVIDENCE In prison, Dominic’s mental health deteriorated. In the 10 weeks that Dominic was in prison he was seen by at least eight medical professionals. Despite a decision that he should be assessed by a psychiatrist, he remained on a waiting list in the month before his death, and never received an appointment.The inquest heard evidence relating to the provision of mental healthcare at the prison by private provider Practice Plus Group Ltd. PPG are outsourced to provide mental health care to prisoners across 45 prisons in the UK. They formerly operated under the name of Care UK.At Leeds prison there are approximately 5,000 prisoners arriving each year, many suffering from mental health issues. However, the inquest heard that a psychiatrist is only available for three days per week. As a result, the mental health team at Leeds is mainly a nurse-led service, despite the fact that a doctor is responsible for the diagnosis of mental illnesses, prescribing medication and seeing prisoners with severe or complex conditions. The inquest heard that there was concern about the adequacy of the psychiatric doctor provision and whether this was sufficient to meet the needs and provide psychiatric treatment for a large prison population.Dominic was seen by a mental health nurse on 14 July 2020 and deemed to require assessment by a psychiatrist. He was paranoid and reported hearing voices but staff did not believe the threshold for opening an ACCT had been met. A mental health nurse working on behalf of PPG identified the “possibility of emerging psychotic features” and suggested engaging in treatment as soon as possible would help. Shortly after this, Dominic’s mother contacted the prison to report a concerning paranoid conversation in which Dominic referred to a gun, a secret room in the prison and an unknown person trying to kill him. Yet still no psychiatrist appointment was made.CONCLUSIONSThe family are disappointed that the jury concluded that it was not clear whether, had Dominic seen a psychiatrist sooner, this would have prevented his death. The jury also noted in their conclusion that there were complications with Dominic accessing legal correspondence and his money, but could not say whether this contributed to his death. However, based on the evidence of the inquest the coroner has now issued a report to prevent future deaths. In it, he raises several issues concerning the provision of healthcare Practice Group Plus, including: “Concern was expressed in the course of the inquest that the meagre provision of psychiatric consultant availability might deter mental health nurses from making referrals. This concern was not accepted on behalf of PPG. Despite this the concern remains that a self-fulfilling prophecy has inadvertently been created in which referrals are not made because there is no resource to respond to any which may be made.”The same coroner raised identical issues in a previous inquest into the death of Mohammed Irfaan Afzal at Leeds prison on 4 August 2019. In Mohammed’s case, the jury concluded that despite an urgent referral to a psychiatrist, no appointment had been provided before his death three weeks later and “it is possible that the delays in providing treatment contributed more than minimally to Mr Afzal’s death."Katherine Noble, Dominic’s mother, said: “If I was to attend a fresh inquest I would be insisting that all of my evidence was presented to the jury. I was able to present emails to and from the prison regime regarding some of the issues Dominic was having with the prison, there was no opportunity to present further evidence that I had that would have (I believe) brought the jury from an ‘unclear’ to a ‘did contribute to his death’. It is beyond me how we in this country can consider ourselves a civilised society when we treat people in the way that Dominic and others are. If Dominic had been an animal, he would have been afforded better care. If Dominic had been an animal the carers would have been charged with cruelty! I have also lost all confidence in the police because this all started as a domestic incident. They still have not returned his equipment to me. I will never ever rely on them again. I also have no confidence in the prison system as being honest when they blatantly lie. Practice Plus Group changed its name because it wanted to rid itself of a reputation earned under the old name. A significant proportion of their nurses are not permanent in the prison and some lack the necessary experience to make valued judgements on the mental health of a person they have had little contact with. In addition, when a person is put forward to see a qualified practitioner they need to know how long the waiting list will take before they get the help they need. Dominic faced the same issues in the community, when another waiting list never got back to him. In my opinion the prisons need to have an ombudsman with teeth. Time and time again a prison is told to make changes and then fails to do what it has agreed to do. On some occasions they can disagree with changes required! Leeds prison had been told to stop using showers as a punishment prior to Dominic entering the prison, yet they still applied it to Dominic even though it was illegal to do so. He was locked alone in his cell for 23 hours or more each day, which meets the official definition of solitary confinement. Some days he threw his food away because ‘it smelt of poo’ (poo wasn’t the word he used). Prison officers closed vents on hot days, removed spare clothing from prisoners on the hottest days and all while the heating remained on. I could go on and on and on with numerous complaints of potential criminal behaviour, as witnessed and given in a live testimonial from my son as supporting evidence. Dominic was on remand but treated as a convicted prisoner. So, even if they are told to make changes as recommended by the coroner, will it actually happen? The support given to the family after Dominic’s death from the prison was abysmal. We were lied to. We were talked down to. We were met with complete disrespect, and that was repeated again at the inquest from representatives of the prison who should have presented themselves honestly in a more formal and professional manner.” Jodie Anderson, senior caseworker at INQUEST who is supporting the family, said: “It is a national scandal that mental and physical healthcare provision in prisons is carted out to the cheapest provider. Dominic’s case is at the sharp end of a prison service that puts profit before care, leaving thousands of vulnerable people like him in limbo awaiting assessments or deprived of psychiatric input. It is regrettable that the jury did not provide any further detailed findings of fact, but the Coroner’s report to prevent future deaths makes clear that unless providers such as Practice Plus Group improve their service, more prisoners will die needlessly. Without an oversight mechanism that can monitor and implement recommendations, repeat failings identified by the PPO, juries and coroners will continue to have fatal consequences."Natalie Tolley, Stephensons Solicitors LLP, who represent the family said: “Dominic’s family were keen that their concerns were explored during the course of the inquest. The legal mail and monies, whilst these may appear trivial, were beyond Dominic’s control and as it was his first time in custody, caused Dominic clear distress. Whilst it was accepted that Dominic had not given cause for concern with regards to any suicidal ideation, it is concerning that, despite comments made and concerns raised by Dominic’s mum, an appointment with a psychiatrist was not prioritised. Hopefully, the PFD will allow for those who need psychiatric assessments to be seen in a more timely manner.”ENDS NOTES TO EDITORSFor further information please contact Lucy McKay on [email protected] Dominic’s mother is represented by INQUEST Lawyers Group member Natalie Tolley of Stephenson’s solicitors. She is supported by INQUEST Senior Caseworker Jodie Anderson. Other Interested persons represented are HMP Leeds and Practice Plus Group.Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.The latest statistics on deaths and self-harm in prison in England and Wales (published 27 January 2022) showed a record high of 371 deaths in prison in the past year, with 86 self-inflicted deaths, an increase of 28% from the previous 12 months.Other relevant cases involving Practice Plus Group: Nile Dillon died in HMP Stocken in March 2018 from a severe asthma attack. Practice Plus Group provided healthcare to the prison at the time of Nile’s death. See media release, October 2021. Winston Augustine was found hanging in his cell in HMP Wormwood Scrubs in August 2018, in a state of ketoacidosis suggestive of starvation. See media release, May 2021. Jamie Bennett died in 2020 from a drug overdose just days after release from HMP Moorlands. Jamie was released to a bail hostel which Practice Plus Group provided healthcare to. See PFD report. Colin Blackburn died by ligature in July 2019 at HMP Hewell. The inquest concluded that a failure to adequately assess his risk of suicide probably caused or contributed to his death. The Record of Inquest set out 14 separate failings which are repeated in the PFD Report, which also criticised the care provided by Practice Group Plus. See PFD report. Gareth Slater died in September 2020 at HMP Dovegate from a brain tumour. Gareth had reported experiencing severe headaches and his face drooping on one side over a week before he was taken to hospital. The jury recorded two missed opportunities by prison staff to seek hospital assistance. Azaz Sheikh died in June 2020 at HMP Doncaster. He was an adult with suspected learning difficulties who took his own life, despite two attempts to do so the previous day. This is at least the eleventh self inflicted death at HMP Doncaster since 2019. INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people.Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.