20th May 2016

Monday 9 May - Thursday 19 May
Liverpool Coroner’s Court, Boundary Street, Liverpool, L5 2QD
Before Senior Coroner Andre Rebello
Counsel for the family:  Ifeanyi Odogwu

Lee was a vulnerable 24-year-old man. This was his first time in prison. He was remanded to HMP Liverpool and had been there for just 6 days before he died. 

On Wednesday 28 January at 1.42pm, a prison officer went to collect Lee for his video link court hearing. Lee was found hanging in his cell and after efforts to resuscitate him, Lee was pronounced dead at 2.17pm. After hearing evidence for 7 days, the jury concluded that Lee did not intend to take his own life.  In a comprehensive and highly critical narrative verdict, they found that Lee died from an accidental death contributed to by neglect, along with a number of significant failings by the prison and healthcare staff.

The jury heard evidence that a real and imminent risk of self-harm or suicide was recognised on Lee’s reception into prison by the opening of an Assessment, Care in Custody & Teamwork (ACCT).  However, the jury concluded that the risk was not managed adequately and effectively by the prison during Lee’s time under their care.  The jury found a number of failures in the inadequate and ineffective management of the risk including:

  • Failure to discuss Lee at the relevant mental health meetings despite being referred on 2 separate occasions;
  • Failure to recognise Lee’s level of vulnerability as part of the ACCT process:
  • Failure to fully explain the PPU telephone system which removed a major protective factor in him not being able to telephone anybody:

    ● Ineffective use of the cell share risk assessment, leaving Lee alone at a high risk of self-harm / suicide:

    ● Numerous failures in carrying out the ACCT process, including lack of communication, failure to follow procedures, missed opportunities to increase observations, failure to take a multidisciplinary approach, lack of ownership of issues, missed opportunities to hold review meetings, and failure to record information on documentation:

    ● Inadequate management of drug dependency including missed treatments, inconsistent treatments, lack of continuity and lack of recording.  The jury considered this more likely than not contributed to Lee’s intentions concerning self-harm or not:
  • A failure to adequately and effectively assess Lee’s mental health in addition to the drug dependency presentation:
  • A failure to properly investigate a prisoner assault on Lee a few days prior to his death despite Lee having expressed his fear to the prison staff.  The jury considered that it was more than likely that this incident added to Lee’s vulnerability given his mental state.

The jury concluded that Lee was in a dependent position due to mental illness and incarceration.  They stated there was a “failure to provide and procure basic medical attention” and there was a “gross failure” in his mental health care which could have saved or prolonged his life.  The jury listed the following findings which they considered causative:

  • Lack of consistent and sufficient mental health assessment:
    ● Assumption of [steps taken by] others:
    ● Vulnerable prisoner in a single cell:
    ● Failure to take action based on observation in ACCT:
    ● The lack of understanding or sufficient explanation for Lee about the Public Protection Unit (PPU) telephone system:
    ● The inability for Lee to send a message to his family.

The Coroner has compiled a Prevention of Future Deaths report in connection with the issues identified by the jury.

Lee’s family is devastated by his death but are pleased that the jury recognised the systemic failures in the care that was provided to him.  They hope that the prison will now implement changes to ensure these failings are never repeated.

Leanne Dunne, solicitor representing the family, said:

“It is important that the failures in the level of care provided to prisoners are recognised and the jury’s findings in this case highlight some of these issues. Not only do these failures have a devastating impact on families but also link in with the wider social issues regarding the fact that prisoners should at least be provided with the same level of medical care that they would be provided within the community.’

Deborah Coles, Director of INQUEST said:

“At a time when prison reform is on the agenda, this case exemplifies everything that is wrong with the prison system.   It is deplorable that a vulnerable young man in need of mental health support can die in this way where neglect and gross failures are identified as a contributory factor.  Urgent and decisive action is needed now to prevent further deaths. This situation can no longer be tolerated.”

INQUEST has been working with the family of Lee Rushton since July 2015.  The family is represented by INQUEST Lawyers Group members Chris Topping and Leanne Dunne from Broudie Jackson Canter Solicitors and Ifeanyi Odogwu from Garden Court Chambers.


Notes to editors:

For further information, please contact: Selen Cavcav at [email protected]