Jury finds a “series of interconnected system inadequacies and failures” contributed to the death of 26 year old Levi Cronin at HMP Highpoint

2nd November 2016

Levi entered HMP Highpoint in August 2014 after a sentence for bike theft in April of that year. He had a history of mental health problems which were known to the prison and was receiving treatment from the prison mental health services.

The jury heard evidence throughout the inquest that Levi was a well-liked but sensitive and vulnerable young man. He died after using a ligature in the prison shower room on 20th September 2014.

Levi was the fourth prisoner to die from self inflicted injuries at HMP Highpoint between April 2013 and September 2014.

Inquests into the deaths of David Smith, Steven Trudgill and Callum Brown at HMP Highpoint all expressed concern at the prison's failure to learn lessons and provide a safe environment for vulnerable prisoners.

Concluding the inquest, the jury recorded that there was a “series of interconnected system inadequacies and failures” which contributed to Levi’s death:

1. Insufficient recording of information, for instance concerning Levi’s welfare.
2. Insufficient communication between departments concerning Levi’s welfare.
3. Inadequate staffing levels resulting in the failure of the offender supervisor to see Levi in good time and the failure to follow up referrals to the mental health team and arrange subsequent appointments.
4. Inadequate support and supervision to the mental health team.

The Coroner will be issuing a prevention of future deaths report noting concerns around the recording and sharing of information by prison and healthcare staff.

Levi’s sister Maureen said:

“We feel that Levi’s death was completely avoidable and it is a tragedy which has greatly affected our family. We are very grateful to the jury for the immense care they took in listening to the evidence throughout the inquest and their courage in providing their conclusions. We implore those responsible for caring for vulnerable people in custody to heed the jury’s concerns so that such deaths might be avoided in future”.

Lawrence Barker from Bindmans Solicitors, acting on behalf of Maureen Cronin said:

“The jury’s conclusions in Levi’s case highlighted areas of very significant concern that were common across the four self-inflicted deaths that occurred at HMP Highpoint during an 18 month period. Both the prison and the prison healthcare provider repeatedly asserted that lessons have been learnt and improvements made, however it is clear from the areas identified by the Coroner for his Prevention of Future Deaths report that serious concerns remain around the treatment being provided to vulnerable individuals. It is the hope of the family that there might now be meaningful change”.

Deborah Coles, Director of INQUEST said:

“Sadly there is nothing new about these findings - the same systemic failings are reported month on month. How many more warnings about the perilous state of prisons are needed from jury findings at inquests, coroner’s reports, prison inspection and monitoring boards and prison staff? Why are these warnings never acted upon?”.


INQUEST has been working with the family of Levi Cronin since 2014. The family is represented by INQUEST Lawyers Group members Lawrence Barker from Bindmans Solicitors and Jesse Nicholls from Doughty Street Chambers.


Notes to editors:

Levi's death was the fourth of four self inflicted deaths at HMP Highpoint between April 2013 and September 2014.

Levi Cronin - date of death 20/09/2014 - HMP Highpoint - aged 26
David Smith - date of death 24/05/2014 - HMP Highpoint - aged 38
Steven Trudgill - date of death 09/01/2014 - HMP Highpoint - aged 23
Callum Brown - date of death 08/04/2013 - HMP Highpoint - aged 25
Source: INQUEST Casework and monitoring

• The inquest for David Smith concluded in August 2016
• The inquest for Callum Brown concluded in January 2016
• The inquest for Steven Trudgill concluded in May 2016

For further information, please contact Shona Crallan [email protected].
For media queries, please contact Laura Smith 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