21st December 2016

Before HM Coroner Andrew Haigh
South Staffordshire Coroners Court.


An inquest jury concluded that the death of 18-year-old Josh Collinson was contributed to by failures on the part of the prison staff at both HMPYOI Parc and HMPYOI Swinfen Hall.

Josh Collinson was 18 years old when he was found hanged in his cell at HMPYOI Swinfen Hall on 3 September 2015. He had been transferred from HMPYOI Parc the previous day.

Josh had a known prior history of mental ill health and learning difficulty, and incidents of self-harm in custody. Whilst in custody, Josh was recognised as a vulnerable child and, after turning 18, as a vulnerable adult.

The inquest heard that while at HMPYOI Parc Josh had self-harmed at least six times and had been under an ACCT for most of his time there. However, Josh was not referred to a Consultant Psychiatrist and was not provided with any therapy tailored to his needs. Additionally, despite the fact that the learning disability team reviewed Josh using a behavioural management plan, few officers were aware of the plan.

The jury heard that the decision to transfer Josh was made due to population pressures rather than Josh’s needs and vulnerabilities and without any consultation with his offender manager or supervisor.

At Josh’s reception at HMPYOI Swinfen Hall he was not recognised to be at risk of self-harm or suicide despite having told a reception nurse that he had tied a ligature the previous day.  Staff at Swinfen Hall were unaware of its own policy that prisoners undergoing transfer were at particular risk of self-harm and suicide and that caution was appropriate.

The jury concluded that given the numerous known risk factors and triggers for Josh an ACCT should have been opened immediately on reception at Swinfen Hall in order to ensure that he was monitored through his first night.

The jury found the following were probable contributory factors to Josh’s death:

  • Josh’s learning disabilities made it difficult for him to cope with prison life
    • The failure of anyone to read the psychological report which was entered onto System One (if it had been read it could have led to more appropriate treatment to meet Josh’s needs)
    • The failure of HMPYOI Parc to provide a multidisciplinary joined-up approach
    • The failure of HMPYOI Swinfen Hall to open an ACCT
    • The failure in training to adhere to and review relevant policy and systems at both HMPYOI Parc and HMPYOI Swinfen Hall.

The Coroner stated he will write a prevention of future deaths report to NOMS to recommend the implementation of a clear policy on transfer which ensures that a prisoner’s particular vulnerabilities are considered.

Josh Collinson’s family said:

“We feel that the inquest has properly examined all factors surrounding Josh’s death at HMPYOI Swinfen Hall and we believe the process has addressed our concerns in respect of failings in the level of care and protection at both HMPYOI Swinfen Hall and HMPYOI Parc.

We hope the conclusions of the Jury and subsequent recommendations of Coroner Haigh will help to finally cultivate a culture of care and compassion within the prison system, and provide a more adequate level of care to those prisoners like Josh that are especially vulnerable, young, suffering from mental health issues and learning disabilities. Ultimately we hope the lessons learned can prevent any unnecessary deaths in custody in the future.

Josh was a loving, protective and thoughtful brother, son, and uncle. Josh will be remembered for his unique inquisitive and enthusiastic child-like nature to all things. An endlessly fascinating boy who will be deeply missed by family and friends.”

Deborah Coles, INQUEST Director said:

“Josh’s death was preventable. This is yet another example of the catastrophic consequences of failures in assessment of vulnerable prisoners and the sharing of information.

"The failures to protect vulnerable teenagers with mental ill health and learning disabilities were well documented in Lord Harris’ review of the deaths of young people. The failure of government to implement the Harris Review recommendations is resulting in the ongoing number of people dying alone and in despair in prisons. This is shameful.”


INQUEST has been working with the family of Josh Collinson since September 2015. The family is represented by INQUEST Lawyers Group members Mark Scott and Miri Weingarten from Bhatt Murphy Solicitors and Sam Jacobs from Doughty Street Chambers.



For further information, please contact: Shona Crallan at [email protected] or
Gill Goodby at [email protected].

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.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing