4th November 2015

Neal Price was a 26 year old man who had a history of mental health issues and a diagnosis of Schizophrenia. On the 4th March 2014, Neal was found in his cell at HMP Forest Bank with a plastic bag wrapped around his head. He was pronounced dead at the scene. Neal had spent time in prison prior to this occasion and had also spent time in psychiatric units after being detained under the Mental Health Act. He had been under a section 3 at the time of his remand into custody.The Inquest heard that Neal was arrested on the 12th January 2014 whilst he was on s17 leave from the psychiatric unit. He had missed his last depot injection. Whilst in police custody he was seen by his criminal solicitor who had known him over a period of 15 years, he described Neal’s behaviour has being bizarre and out of the ordinary and had concerns about his fitness to be interviewed. Neal was also seen by a FME from Medacs who assessed Neal as being fit. His CPN attended the police station and without any assessment of Neal agreed with the FME’s assessment. Due to the concerns of the police and his criminal solicitor a charging decision was requested from the CPS without interview and Neal was charged and detained to appear before the courts the next day. Whilst in police custody he told officers that he would kill himself if released.

The next day markers were recorded on his Person Escort Record from GMP regarding a self harm and suicide risk and also details of his mental health condition. A custody officer from GEOAmey, who also knew Neal since he was approximately 16 years old, was so concerned about his behaviour and the risks recorded on the PER that she opened a Self Harm and Suicide Warning Form (SASH) whilst he was in the custody of the courts. She gave evidence that in the 10 years that she had known him she had never seen him behave in the way in which he presented and that she could tell that he was ill. That same day he was seen by his CPN who assessed him as being fit to plead and did not note that his behaviour was any different from normal. Neal was remanded into custody that same day. Due to the Custody Officer’s concerns she contacted HMP Forest Bank and advised a Senior Prison Officer that Neal was on an open SASH, Neal’s PER and the SASH went with him to the prison.

On arrival at HMP Forest Bank Neal was seen by the same Senior Prison Officer, two other prison officers, a healthcare assistant and a Nurse and despite what was recorded on the PER and the fact that he was on an open SASH not one person decided to open an ACCT. Evidence was not heard in court from the Senior Prison Officer due to him being abroad at the time of the Inquest, but evidence heard from the other witnesses was that in hindsight an ACCT should have been opened.

A referral was made to the Mental Health In Reach Team (MHIT) and Neal was housed on the Healthcare Wing due to the fact that he was still under a section. Contact was made with the hospital and on the 17th January his section was rescinded, after which he was relocated to normal location. He had a mental health assessment on the 20th January where he disclosed current thoughts of suicide, feelings of depression and concerns about losing his home due to him being in prison.

On the 26th January there was an incident where Neal had to be relocated to healthcare due to the fact it was believed he had taken Black Mamba and he was exhibiting bizarre behaviour. He was relocated to normal location the next day. After this time Neal failed to attend any appointments with the MHIT.

Over the following weeks Neal moved wings a number of times due to getting into debt. During the Inquest the jury heard of the risk of bullying when debts are owed in a custodial environment.

On the 26th February whilst having his depot injection Neal told the Nurse that he was suffering from side effects of the depot and that it was not reducing his “violent thoughts”. The nurse did not seek to clarify what he meant by this and Neal was returned to his cell. Although the Nurse emailed the MHIT, Neal was not seen by anyone from the Team about those thoughts following that disclosure before his death. The nurse from the MHIT who picked up that referral but failed to action it was disciplined and that the manager of the MHIT accepted that this was a failure.

At around 5.05am on the 4th March Neal was found in his cell with a plastic bag wrapped round his head. His father, Anthony Price, told the jury on the first day of the Inquest that this date was the anniversary of Neal’s mother’s suicide. He went on to say that she had died 15 years earlier of an overdose and that Neal had never recovered from this, and that he felt Neal’s mental health problems stemmed from that event.

The Jury returned a conclusion of suicide but was not able to say on the balance of probabilities whether had Neal had a further mental health assessment it would have prevented his death on the 4th March.

HM Assistant Coroner Mr McLoughlin ruled that he did not need to use his powers under Regulation 28 due to being satisfied that the prison has made the necessary changes to deal with the issues and failings that arose from Neal’s death. Evidence was heard at the Inquest about various changes that have been put in place by HMP Forest Bank, there is now routinely a Nurse in reception as part of the screening process alongside the healthcare assistant, if there are any anniversary’s like the one in Neal’s case that are flagged up to staff they are to be recorded on NOMIS for operational staff to be more vigilant on those dates, there are posters in reception and throughout the prison highlighting the risk of suicide and self harm and reminding staff that an ACCT should be opened if they have any concerns and finally further in depth training has been provided to all staff across the prison in respect of ACCTs and risks of suicide and self harm. In dealing with the mechanism in which Neal took his own life the prison have introduced specifically designed plastic bags for use in the prison which are appropriately ventilated and have the details of the Samaritan’s printed on them and they have written to NOMs to recommend it as good practice nationally.

The family of Neal said:

"We would like to thank INQUEST, our barrister Laura Nash, Lester Morrill Solicitors, and specifically Gemma Vine and Charlie Myers for their hard work in trying to achieve a satisfactory outcome. We would especially like to thank Lynn Berry from GEOAmey for recognising Neal’s plight, and making efforts to try to protect Neal and to warn the prison of his vulnerability.

It is extremely disappointing that having received this information it was not acted upon by the prison staff and Neal’s mental health was not assessed until six days after he arrived at HMP Forest Bank. Furthermore, when that assessment was carried out his expression of current suicidal thoughts was not addressed. Also, when Neal disclosed that he was suffering with violent thoughts these were not explored. This should have resulted in a further assessment and possibly an ACCT being opened. We are also disappointed that Neal was not able to see a psychiatrist in the seven weeks that he was in HMP Forest Bank."

Deborah Coles, co-director of INQUEST said:

 "This is the third inquest which concluded in the last three weeks involving a prisoner with mental health problems.   Distressing details of these deaths show that mental health services in prison are under severe strain.   It is shameful that a decision was made to send someone like Neal to prison in the first place.    Changes that have been implemented, whilst welcome, should have already been in place.  What is vital now is for the action taken to be disseminated nationally.”

INQUEST has been working with the family of Neal since December 2014. The family is represented by INQUEST Lawyers Group members Gemma Vine from Lester Morrill Solicitors, Leeds and barrister Laura Nash from St John's Chambers