28th February 2014

Combined Courts Centre, Stafford
In front of Staffordshire Coroner Andrew Haigh

A jury has concluded that a breakdown in communication between Lincoln, North Sea Camp and Stafford prisons contributed to Kieron Dowdall’s death at HMP Stafford and the way in which information was not processed or acted upon between prison departments and not least with Kieron also contributed to his death.  They ruled Kieron Dowdall hanged himself on 27 January 2012 with the intention of killing himself. 

Kieron’s family said:

“We are grateful for the jury’s findings and the way they approached the case. Kieron was so well loved by so many people. If this never happens to another prisoner Kieron’s death won’t be in vain.”

Victoria McNally, INQUEST caseworker for the family said:

“It is deeply concerning that Kieron’s tragic death arose in circumstances involving such basic failures of prison procedure and communication. He was a highly vulnerable young man and should have received better treatment and protection. It is imperative that the issues in his case and the learning from his death are properly understood and implemented at both local and national level.”

Kieron Dowdall was 18 years old when he was remanded to a Young Offenders’ Institution on 16 April 2006. He was given an indeterminate sentence with a minimum tariff of 3 ½ years. By the time of his death he had spent almost six years in prison custody.

In October 2010 Kieron was moved to North Sea Camp (an open prison) as part of his release plan.

By early January Kieron’s mood and mental health had significantly deteriorated. He temporarily absconded, saying he intended to take his life. He was moved temporarily to Lincoln Prison due to his vulnerability and the danger to himself which meant he could not safely be looked after in an open establishment. An ACCT document was opened (Assessment, Care in Custody and Teamwork – the system used for prisoners at risk of self harm) but despite a serious attempt the following day to cut his wrist, this was closed within a matter of days.

Although expecting to be returned to North Sea Camp prison, Kieron was transferred without warning or explanation to HMP Stafford, with no attempt at Lincoln to re-evaluate his risk. His ACCT document, still awaiting a post closure review, did not travel with him. When it was faxed and posted to Stafford, nobody saw or considered it.

In the days following his transfer, Kieron had a number of telephone conversations with his family, expressing feelings of hopelessness. On the 25 January, despite urgent attempts by his family to speak with relevant prison staff to raise their concerns, his family were not given access to staff and were told to put their concerns in writing.

In the early hours of 27 January 2012, Kieron Dowdall was discovered by staff hanging from a ligature in his prison cell.

Evidence at the inquest revealed that mandatory instructions for caring for a desperate and confused prisoner who had self harmed were not followed in Kieron's case, and without warning he was returned to a closed prison after 15 months in open conditions, without the crucial documentation detailing his history of a serious suicide attempt 10 days previously.

The Prison and Probation Ombudsman's report, and that of a Clinical Reviewer, criticised an over reliance upon his "self reporting" that he would not harm himself again instead of a holistic appraisal of all his circumstances.

Senior officers told his Inquest that they would have cared for him far differently had they known of his background, and not left him in a cell alone the night he killed himself. A healthcare nurse said that he told her on the last morning of his life that he was struggling daily and felt he was having a breakdown, but she never passed this on to wing staff.

INQUEST has been working with the family of Kieron Dowdall since May 2012. The family is represented by INQUEST Lawyers Group member Ruth Bundey of Harrison Bundey solicitors.


Notes to editors:

Kieron’s case will be considered as part of the independent review the government has recently announced into the deaths of 18-24 year olds in prison.