Media Media releases Inquest concludes that systematic failures and consistently missed opportunities caused death of Ryan Harvey at Woodhill prison 23 January 2019 Before HM Senior Coroner for Milton Keynes Tom OsborneH.M. Coroner’s Court, 1 Saxon Gate East 15 – 22 January Ryan Harvey was 23 when he died on 8 May 2015, after he was found hanging in his cell in HMP Woodhill five days prior. The inquest into his death has concluded finding numerous failings contributed to his death. Ryan’s was the eighth in a series of 18 self-inflicted deaths at HMP Woodhill over a three-year period (2013-2016), and the fourth on the induction wing. Ryan Harvey had learning disabilities which affected his ability to communicate and to understand the consequences of his actions. At school he had had a Statement of Special Educational Needs. At the time of his arrest he was living in supported accommodation. His family say he wasn’t vindictive, or a nasty kid, he just didn’t fit into this world and didn’t think things through. Ryan had been in the prison since 22 April 2015, on the induction unit. Healthcare staff had been informed that Ryan was a vulnerable adult prior to his arrival but no proper assessment had been carried out and the information was not shared. The inquest heard that Ryan was seen in his cell on 2 May with a ligature around his neck, which prompted the opening of suicide and self-harm prevention measures known as ACCT. The following evening, on 3 May, Ryan was seen trying to tie a ligature around his neck to the light fitting. His observations were raised from hourly to two an hour. However, no action was taken to enter his cell and remove the ligature. He was found hanging later that evening and died on 8 May. At the inquest the family heard some prison officers defend the actions taken, whereas others accepted that there were failings and that the cell should have been opened. The jury concluded that the following failures contributed to Ryan’s death: to share and use the relevant information to carry out appropriately the ACCT procedures When Ryan was discovered at about 8.30pm on 3 May trying to tie a noose [ligature] to a light fitting there was:- a failure in communication between members of staff concerning the ligature that was seen around his neck;- a failure to remove the ligature from the cell;- and a failure to consult and review his ACCT document following this event Additionally, the jury found a failure by healthcare staff to undertake an adequate assessment of Ryan’s learning disability, and to conduct an assessment of his mental health, may have contributed to his death. The jury stated that prior to Ryan’s ACCT assessment, staff had insufficient knowledge of relevant information about Ryan’s background. They also found that during the ACCT procedures there was a consistently unsatisfactory application of the guidelines, and that each level of the ACCT failed to sufficiently safeguard Ryan and his immediate needs. Custodial Manager Joseph Travers stood trial in January 2018 for the offence of manslaughter. He had been in charge of the prison on the evening of 3 May 2015. He was acquitted and the Old Bailey jury provided a statement in which they recorded their view that the case has thrown up a number of “appalling systematic failures to provide front line staff with sufficient information as to the inmates background”. The most recent inspection of HMP Woodhill found the prison is “still not safe enough”, and there have been more concerning deaths this year and last. Jo Eggleton, a solicitor from Deighton Pierce Glynn who acted for Ryan’s family said: “These failings are some of the worst I have seen at HMP Woodhill. Ryan was failed at all stages and by almost everyone during his 11 days in the prison. It's not surprising that there was a criminal prosecution, one that Mr Justice Green remarked was properly brought. It's particularly concerning that a number of those involved still stand by their actions despite the high level of scrutiny and criticism their actions have received in the last three years.” Selen Cavcav, the INQUEST caseworker who has supported many families bereaved by deaths in HMP Woodhill said: “Ryan’s vulnerability and risk could not have been clearer, but he was essentially left in his cell to die. As such, almost four years on and after a series of deeply critical inquests, it was frustrating to see a continued attempt by some Woodhill staff to defend the indefensible. After so many preventable deaths, there is not sufficient evidence of a shift in culture and practice that would stop this from happening again. Indeed, this month there has been another self-inflicted death at Woodhill, which inspectors recently found is still not safe. This inquest also highlights wider concerns about the treatment of people with learning disabilities in prison, which must be considered at a national level.” ENDS NOTES TO EDITORSFor further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected] Ryan’s family are represented by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn and Nick Armstrong of Matrix Chambers. In 2017 there were no self-inflicted deaths at the prison. In 2018 there was one self-inflicted death, as well as one homicide and three deaths which await classification. On 4 January 2019 Darren Williams was found hanging at the prison and died. The recent inspection of HMP Woodhill, published in June 2018, found the prison has ‘deteriorated significantly’ since the previous inspection in 2015 and is ‘still not safe enough’. See INQUEST response (June 2018). A total of 18 self-inflicted deaths took place in HMP Woodhill between January 2013 and December 2016 when concerns were first raised at the inquest into the death of Kevin Scarlett (March 2014): Kevin Scarlett was found hanging in his cell and died on 22 May 2013 aged 30. David Hunter was found hanging in his cell and died on 26 May 2013 aged 28. Sean Brock was found hanging in his cell and died on 10 November 2013 aged 21. Stephen Farrar was found hanging in his cell and died on 12 December 2013 aged 25. Dwane Harper was found hanging in his cell and died on 4 April 2014 aged 33. Jonathan White was found hanging in his cell and died on 14 October 2014 aged 37. Daniel Byrne was found hanging in his cell and died on 27 February 2015 aged 29. Ryan Harvey was found hanging in his cell and died on 8 May 2015 aged 23. Ian Brown was found hanging in his cell and died on 17 May 2015 aged 44. Joanna Latham was found hanging in her cell and died on 27 November 2015 aged 38. Simon Turvey was found hanging in his cell and died on 29 December 2015 aged 27. Ireneusz Polubinski was found hanging in his cell and died on 31 January 2016 aged 58. Robert Fenlon was found hanging in his cell and died on 5 March 2016 aged 35. Michael Cameron was found hanging in his cell and died on 28 April 2016 aged 45. Thomas Morris was founding hanging in his cell and died on 26 June 2016 aged 32. Daniel Dunkley was found hanging in his cell and died on 2 August 2016 aged 35. David Reynor was found hanging in his cell and died on 25 August 2016 aged 41. Jason Basalat was found hanging in his cell on 11 December 2016 aged 52. Over that period HMP Woodhill had the highest number of self-inflicted deaths of any prison in England and Wales. Families bereaved by this series of self-inflicted deaths in HMP Woodhill were granted a judicial review aiming to address the high number of self-inflicted deaths in Woodhill. In May 2017 the High Court rejected this claim, however since the hearing highly critical inquests have found: The failure by HMP Woodhill to learn from previous suicides caused the death by neglect of Daniel Dunkley(May 2017) HMP Woodhill authorities failed to take all reasonable precautions to prevent the death of Tom Morris (July 2017) Following the public pressure brought by the families involved in these cases, an independent review by Stephen Shaw was commissioned in May 2017 to examine the circumstances of these deaths. Following this, it was announced that Woodhill would convert from a local prison to a category B training establishment. At the inquest the Woodhill Governor, Nicola Marfleet, said the re-functioning of Woodhill, originally planned for March 2018 was now planned for September 2019. She agreed with the Independent Monitoring Board that the uncertainty around the prison’s future is demoralising for staff.