Media Media releases Inquest into the death of luke McDonnell at HMP Lincoln concludes 17 August 2016 Lincoln Coroners CourtHMC Stuart Fisher Late yesterday, an inquest jury returned an open verdict following the death of 29 year old Luke McDonnell at HMP Lincoln. Luke McDonnell had a history of mental health difficulties and a record of serious and repeated self harm. The jury concluded that Luke hanged himself on the 14 June while left in a cell on his own. He was found by prison staff on the day of his 29th birthday, just eleven days after his arrival at the prison. Rejecting a conclusion of suicide, the jury found that the prison had failed to follow important safeguarding procedures, including a failure to appoint a case manager to oversee Luke’s ACCT reviews (procedures required for the protection of prisoners at risk of self harm). The jury also found staff responsible for his care had at times failed to check records providing important information about his history of self harm.During his time at Lincoln, Luke had complained of being assaulted and bullied by other prisoners. Following two serious incidents of self harm, two A&E discharge letters identified his need for an urgent mental health assessment. The jury found the prison had failed to make this urgent referral. The day before events leading to his death, Luke was moved into a cell on his own. The following day he was found in his cell crying. It was his birthday. That evening he asked to be moved into a shared cell, saying that he was getting stressed on his own. Within a matter of hours, Luke was discovered in his cell unresponsive and was taken to Lincoln County Hospital. He died three days later. Cindy Woodings, Luke’s mother: "The way Luke was treated was a disgrace. The inquest uncovered a host of failings, but did not go far enough." Deborah Coles, INQUEST: “In the past 12 months we have seen the prison system lurch from crisis to crisis. Assaults, self harm, self inflicted deaths, homicides have become endemic. From the time of his arrival at Lincoln it was clear Luke was at risk and yet within two weeks he was dead. Prisons like Lincoln must ensure that vital procedures required for the protection of life are followed to stop this shocking tide of deaths with the devastating impact this is having on families like Luke’s.” Ruth Bundey, the family’s lawyer: “The same old issues arise at Lincoln and other prisons time and time again, with nothing apparently learnt from previous deaths and previous recommendations for change. Inquests like these are truly dispiriting.” The family was represented by INQUEST Lawyers Group member Ruth Bundey, Harrison Bundey Solicitors. Ends Notes to editors: The number of self inflicted prison deaths (England and Wales) has continued to rise over the past five years: 58 in 2011, 61 in 2012, 76 in 2013, 88 in 2014, 88 in 2015 and 60 already in 2016. See INQUEST statistics. In its 2015/2016 annual report, the Independent Monitoring Board identified concerns around the high level of self harm at HMP Lincoln with 413 incidents of self harm reported (compared to 135 in the previous year). Its report can be found here. For further information, please contact: Family’s solicitor Ruth Bundey 07712139236 and 0113 2007400 or INQUEST caseworker Victoria McNally 020 7263 1111. 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.