5 October 2017

Before HM Coroner Ian Pears
Bedfordshire and Luton Coroner Service
26 September - 4 October 2017

Mark Vagnoni, 35, was found hanged in his cell at HMP Bedford, less than 15 minutes after being seen by a prison officer as he played with his bed sheet. He died two days later in hospital on 13 July 2016. Yesterday an inquest jury concluded that a number of serious failures and missed opportunities by the prison contributed to his death.

On 11 July 2016 Mark pressed his cell bell repeatedly, asking for tobacco. When a prisoner officer attended, he was found self-harming in his cell.  Suicide and self-harm prevention measures (known as an ACCT) were opened, and Mark was placed on 30 minute observations. Later that evening Mark was seen by a prison officer running his bedsheets through his fingers. He was found hanging in his cell within 15 minutes. He died in hospital two days later on 13 July 2016.

On 4 October 2017, the jury at the inquest concluded that failures by the prison and healthcare staff had "contributed significantly to his actions and ultimate death" at HMP Bedford. Mark suffered with paranoid schizophrenia. After hearing the evidence, the jury concluded that it was unclear whether Mark intended to take his life and that it may have been a cry for help. They further concluded that:

• The on-going failures to identify and record Mark's risk factors resulted in inadequate monitoring of him on 11 July 2016.
• The failure to open an ACCT on 18 May 2016 when Mark had previously expressed suicidal thoughts was a "missed opportunity."
• Staff who had contact with Mark lacked training in how the ACCT should be used. Since Mark's death, mandatory annual training on this has been rolled out to all staff at HMP Bedford.
• There were systemic failures in information sharing between the prison Healthcare department and the Prison Service, regarding key risk information about Mark.
• If risk information had been displayed more clearly on the prison information system used by officers this would have helped to avert Mark's death.
• The jury also commented that there appeared to be evidence of "significant understaffing" of officers and mental health professionals at the Prison.

On 7 July 2016 Mark was moved from E Wing, a small wing for prisoners undergoing substance misuse recovery, to A Wing, a much larger wing containing over 3 times as many prisoners. The jury believed this move was “excessively speedy” and was made without due consideration of Mark's medical and personal history and risk factors, and that the move from a shared to a single cell "left him extremely vulnerable”.

The family of Mark Vagnoni said:

“Mark was let down by the prison and mental health services. He was clearly unwell and unhappy. He had previously spent long periods of time detained under the Mental Health Act. The prison ought to have done more to protect him. Had Mark been under more frequent observation, his death may have been prevented.

More could have been done to communicate, understand, and document Mark's issues. Several other prisoners have died in similar circumstances at HMP Bedford, suggesting that this is a wider problem.
The Inquest has been difficult and stressful for us. We have felt angry and frustrated that no individual has been willing to accept responsibility for the sudden decision to move Mark from E Wing, where he was settled, to A Wing.
We would urge HMP Bedford and Northamptonshire Healthcare Foundation Trust to make life safer for vulnerable prisoners so that other families do not have to go through the pain that we are going through”

Deborah Coles, Director of INQUEST said:

“Mark is yet another man failed by a prison ill-equipped to deal with the vulnerable people put in its care. The jury identified a range of failings which highlight and reflect systematic problems with prisons and the health services within them. These all too familiar conclusions reiterate the clear need for prison authorities to ensure that all prison and healthcare staff are properly trained in mental health care and suicide and self-harm monitoring (ACCT). The huge number of preventable, self-inflicted deaths in prisons continues. Urgent action is needed to rectify shockingly basic failings found in Mark’s case, and so many others.”



For further information, please contact Lucy McKay on 020 7263 1111 or [email protected]
The family is represented by INQUEST Lawyers Group members Jessie Waldman of Bhatt Murphy Solicitors and Jesse Nicholls of Doughty Street Chambers.

The opening press release can be found here.

INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people.

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