1 February 2019

Media release prepared by Bindmans LLP

Before HM Assistant Coroner Allison Summers and jury
Mid Kent & Medway Coroner’s Court
Inquest Dates: 21-30 January 2019

An eight day jury inquest into the death of 32 year old Michael Alexander Judge from Clacton concluded that he taken his life and highlighted numerous failings at HMP Swaleside which contributed to his death.

Michael was found unresponsive in his single cell on 16 March 2017 with a ligature around his neck. Michael had a history of self harm,  mental health issues and substance misuse.  There were also issues with bullying and debt at the prison. 

On 14 March 2017, Michael told staff that he was thinking about self harming and committing suicide. This led to suicide and self harm prevention measures being instigated with the prison opening a document called an ACCT (Assessment, Care in Custody and Teamwork) to help keep Michael safe.  However, the prison failed to complete the immediate action plan and caremap to reduce Michael’s risk of self harm and suicide.  The ACCT was then closed at his first case review on the morning of 15 March 2017.  This was despite Michael disclosing he had taken a week’s worth of medication during his assessment interview, he had feelings of paranoia and was hearing voices.  The ACCT also failed to address any of the concerns that Michael raised when the ACCT was first opened. 

The prison then failed to reopen the ACCT on the afternoon of 15 March 2017 after Michael told a member of the Mental Health In Reach Team that ‘he had just done a spliff of spice,’ he was still hearing voices and having auditory hallucinations.  No one from healthcare or the prison officers on the wing checked on him. 

Later that evening Michael requested to speak to a Listener.  Listeners are prisoners who are trained by the Samaritans to provide emotional support to prisoners.  Two Listeners attended Michael’s cell around 22.00 leaving around 23.00. Michael was last seen alive by an Operational Support Grade (OSG) Officer in his cell around 23.30.

The jury sitting before HM Assistant Coroner Allison Summers found Michael had committed suicide, but there was a catalogue of failures. They found the closure of the ACCT and the decision not to reopen it on 15 March 2017 was more likely than not to have contributed to his death. Although the prison had systems and processes in place to share historical information about prisoners, staff conducting Michael’s ACCT case review did not review this before closing the ACCT. As a result, the prison was unable to consider relevant information in order to most appropriately assess Michael’s risk of self harm and suicide.

The jury also found that procedures in place to reduce Michael’s risk of self-harm and suicide were not adequately followed. For example, healthcare was not informed about the opening of the ACCT and there was no entry on the prison computer system (NOMIS).  Insufficient information was gathered with staff placing too much reliance on what Michael said during his case review and did not give appropriate weight to other risk factors. The jury found the issues identified in the assessment interview had not been resolved, so it was not appropriate to close the ACCT on the morning of 15 March 2017. Furthermore, the supervising officer on the wing did not respond appropriately after he was told that Michael was under the influence of spice.  The ACCT should have been reopened that afternoon by either In Reach or the supervising officer on the wing with healthcare taking steps to assess Michael.  Furthermore, night staff should have been notified about the closure of Michael’s ACCT, which should have been reopened at or about the time of Michael asked for or had contact with the Listeners. 

Michael’s mother was represented at the inquest by Solicitor Anna Thwaites and Trainee Solicitor Keshina Bouri of Bindmans LLP and Counsel Jude Bunting and Pupil Clare Duffy of Doughty Street Chambers.

Michael’s mother, said: “The prison failed my son at every level. Michael was in crisis and needed help, yet his ACCT was closed prematurely and staff failed to reopen it later that day.  The prison must learn from Michael's death. I believe he would still be here today if the prison had simply done their job.”

Anna Thwaites, solicitor from Bindmans LLP, who represented the family said: “The prison should have done more to keep Michael safe.  Mandatory national and local prison policies on self harm and suicide were simply not followed.  There was a complete lacuna in Michael’s care in the last few days before his tragic death.  Staff failed to engage properly in the ACCT process to ensure that Michael had the support that he so desperately needed.  There was failure upon failure by prison staff, mental health in reach and healthcare in Michael’s care.’