Media Media releases Inquest finds appropriate precautions were not taken to prevent the accidental death of James Connolly in HMP Chelmsford 26 January 2011 The inquest held before HM Coroner for Thurrock and Essex into the death of James Connolly, also known as Jimmy Sullivan, concluded yesterday. The jury found that his death was an accident, caused in part because appropriate precautions were not taken whilst he was detained in prison custody. Jimmy, aged 23, died on 8 January 2008 on B Wing in HMP Chelmsford where he was serving a two year prison sentence for driving offences. Jimmy had a long history of mental illness, but was able to manage well in the community with the support of family, friends, and local outreach teams. In custody, Jimmy had been identified as someone who was at serious risk self harm and he had made a number of attempts to kill himself in the past. Prison staff noted that Jimmy’s “risk of death [from self harm] was extremely high.” Jimmy was transferred from HMP Bedford to HMP Chelmsford in October 2007 where he spent the majority of his time on the healthcare wing, often monitored by constant observations. Jimmy was under the care of two consultant psychiatrists having been diagnosed with Emotionally Unstable Personality Disorder – Borderline Type, with mild learning difficulties. The inquest heard expert evidence from an independent psychiatrist that the symptoms of this disorder included that Jimmy was prone to impulsive actions without consideration of the consequences. Jimmy was keen to be moved to the wing where he could take part in courses to prepare for his life outside prison, but in reality he coped badly when not under the close supervision available in healthcare. Jimmy was transferred to the wing on two occasions in November and December 2007, but despite this being preceded by settled periods in healthcare without any acts of self-harm, he immediately self-harmed when on the wing, on one occasion making a noose and hanging himself until he was fully suspended, after which he had to be cut down by prison officers. The most recent incident occurred on 25 December 2007, less than two weeks before his tragic death. On 31 December 2007 a multidisciplinary team in charge of Jimmy’s wellbeing whilst on healthcare comprising of clinical and prison staff decided that he should not be moved to the wing as there was a significant risk that he would harm himself. One week later a decision was made that Jimmy could go to the wing, but that it would be prudent to place him in a shared cell, with friends if possible. However, on 8 January 2008 a senior prison officer authorised his move to the wing and told prison staff he could be located in a single cell. The officer accepted at the inquest that he did not consult Jimmy’s treating psychiatrists about this, nor did he make any enquiries as to whether he could be located in a cell with friends. The independent expert referred to the move as “decision-making on the fly.” On transferring to the wing, Jimmy was accompanied by extensive documentation setting out his patterns of self-harm and recording the two previous occasions when he had failed to cope on the wing. No oral or written handover was provided by officers on healthcare to officers on the wing, and none of the senior officers in charge of the wing on which Jimmy was located read the paperwork. The prison’s Head of Safer Custody told the inquest that she would expect a verbal handover to take place, ensuring key information is passed between wings. At 9.25pm on 8 January 2008 Jimmy rang his cell bell and told an officer that he was hearing voices telling him to kill himself. The officer spoke briefly to Jimmy and then left, stating he would check up on him in a while. On his return approximately half an hour later he found Jimmy hanging from the cell window bars with a ligature made of bedding. Since Jimmy’s death HMP Chelmsford has accepted a range of recommendations made by the Prisons and Probation Ombudsman, and has introduced a written handover form to be completed whenever a prisoner is transferred within the prison. Jimmy was much loved by his friends and family, and many of the prison and healthcare staff giving evidence at the inquest described how Jimmy was very pleasant to work with. Fran Butcher, Jimmy’s partner and mother of his two children, said: Jimmy was a kind and loving father and partner. His family and friends remain devastated by his death. Nothing will ever make up for the loss we have suffered. I have however found some solace in the Jury’s findings that the prison failed to take appropriate precautions to prevent Jimmy’s death. I hope this will encourage HMP Chelmsford, and others caring for vulnerable people in custody, to improve the care provided to prisoners like Jimmy, and to ensure vital information is passed on within the prison. If Jimmy’s death can prevent other families from going through this terrible ordeal, our suffering will not have been in vain. Deborah Coles, Co-Director of INQUEST, said: It is truly shocking that such a vulnerable young man was left alone at a crucial time when support and intervention from HMP Chelmsford could have made the difference between him living and dying. It is an ongoing concern that prisoners with serious mental illnesses and who are at risk to themselves are being moved to prisons clearly ill-equipped and under-resourced to deal with that level of vulnerability. James Connolly’s partner and children were represented by INQUEST Lawyers Group members counsel Marina Sergides of Garden Court Chambers, instructed by Kat Craig of Christian Khan Solicitors.