22 December 2022

Before Assistant Coroner Ian Dreelan and a jury
Birmingham and Solihull Coroner’s Court
12 – 22 December 2022

Floyd Everton Carruthers, 58, died on 14 June 2021 after not leaving his cell in HMP Birmingham for four days, and not eating multiple evening meals.

An inquest has concluded (on 22 December) finding that the prison staff failed to take sufficient steps to safeguard Floyd, including insufficient record keeping, handovers and escalation. In particular, there was a serious failure to make a referral to healthcare, such that Floyd’s death was contributed to by neglect.

The jury also found that staff were insufficiently trained in safeguarding adult prisoners, in breach of the national policy on adult safeguarding in prisons.

Floyd was from Birmingham. The eldest of four siblings, he always wanted to help his family in any way he could. He is described as a “kind and caring gentleman” who was “quiet but very popular and widely loved”.

Floyd had experienced mental ill health for over 20 years. He had been living in Midlands Heart Housing for 30 years where he had a designated housing officer who was aware of his mental health history and that he was receiving treatment from the community mental health team.

In March 2021, Floyd was reported by the housing association to police for breaching an anti-social behaviour injunction. He was arrested and held in police custody for three days before being transferred to Birmingham prison.

Upon his arrival at HMP Birmingham, healthcare staff noted that Floyd had a pacemaker fitted and that more information was needed. However, this was not followed up.

Following his arrest, Floyd’s family raised their concerns about his welfare directly with the prison. They were assured that he was alright. Floyd’s family also contacted the adult community mental health team but were told that they could not give any further information due to confidentiality.

From 25 May, Floyd did not leave his cell for four days and declined multiple evening meals.

On 29 May, staff unlocked Floyd’s cell and found him slumped in a chair. An ambulance was called and Floyd was transported to Birmingham City Hospital.

Upon arrival at hospital he was diagnosed with sepsis from an infection at the site of his pacemaker. He died in hospital on 14 June 2021.

The inquest concluded that the medical cause of death was cardiac tamponade and hypostatic pneumonia. In addition, Floyd’s death was caused by:

  • A failure by prison staff to make a referral to healthcare (which amounted to neglect);
  • Insufficient steps to safeguard Floyd during the period, including insufficient record keeping, handover and escalation; and
  • A lack of safeguarding training.

The coroner will be issuing a Prevention of Future Deaths Report.

Floyd’s family said: “We are relieved to have the answers we were looking for in relation to Floyd’s death. We are thankful for the jury’s time and engagement throughout the inquest, and in coming to their conclusions, and we hope that lessons are learned by the prison to make sure another family do not have to go through the pain we have over the past 19 months. We loved Floyd immensely and we miss him every day, and we will cherish our memories together.”

Lucie Boase of Broudie Jackson Canter, which represent Floyd’s family said: “Floyd’s family have shown remarkable courage in attending court each day for the past two weeks. It has been immensely difficult listening to evidence about the deterioration in Floyd’s health during his time in prison and the failure by prison staff to respond to this properly.

It is noteworthy that, on 16 December 2022, the Governor of HMP Birmingham issued an Order to staff reminding them of their responsibility to support and monitor the welfare of prisoners, to ensure that individuals who do not participate in the prison regime are cared for appropriately. Sadly this comes too late for Floyd and his family.”

Jodie Anderson, Senior Caseworker at INQUEST, said: Just two months ago INQUEST published a damning report into the preventable deaths of racialised people in prison. Floyd’s death is a sharp reminder of the many premature and neglectful deaths of Black prisoners who are too often deprived of adequate physical and mental health support.

Floyd’s story is also an example of the increasingly brutal and dehumanising process in which statutory services criminalise those with mental ill health. The chain of events that was triggered by Midlands Heart Housing in their approach to Floyd is evidence of a dire need for empathy and compassion in all aspects of social, housing and healthcare provision to ensure there are better alternatives for vulnerable people like Floyd than prison.”


For further information, please contact Lucy McKay on [email protected]

A photo of Floyd is available for media use here.

The family is represented by INQUEST Lawyers Group members Lucie Boase and Nicola Miller of Broudie Jackson Canter and Matthew Turner of Doughty Street Chambers. The family are supported by INQUEST caseworker Jodie Anderson.

The other interested persons represented are the Ministry of Justice, Birmingham Community Healthcare NHS Foundation Trust (BCHC) and Birmingham and Solihull Mental Health Foundation Trust (BSMHT).

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