29th June 2012

A jury at Aberdare Coroners Court has today concluded that 29 year old Shaun Beasley “took his own life in circumstances contributed to by neglect of healthcare and prison”.  Shaun was found hanging in his cell at HMP & YOI Parc on 24 August 2010.

The inquest which started on the 25 June was heard before HM Coroner for Bridgend and Glamorgan Valleys District, Louise Hunt, sitting at Aberdare Coroner’s Court.

HMP & YOI Parc is the only private prison in Wales. It is managed by G4 Securicor, and at the time of Shaun’s death healthcare services were contracted out to Primecare Forensic Medical Services, a national provider of primary healthcare services to prisons, police and other forensic establishments. Shaun was highly vulnerable and suffered serious mental ill health. He had a history of self harm and had made several serious suicide attempts.

In May 2007 Shaun was given an indeterminate sentence with a minimum tariff of two years and 145 days. At the time of his death he had served over three years.

He had been informed at a parole board hearing that he would have to complete a course before being eligible for release. Two weeks prior to his death, he was moved from HMP Littlehey, where he had been for two and a half years and was settled, to HMP Parc where he was told he would be able to take the course. Once he had arrived at Parc he was informed the course was not in fact available at the prison, and he would not be able to take it for another 2-3 years.

The evening of his death he rang his family and told them he could not cope any more. The family immediately rang the prison to alert them. Shaun was already on an ACCT document (Assessment, Care in Custody, and Teamwork – the system used for prisoners who are at risk of self harm) and on half hourly observations. Despite the family’s telephone call observations were not increased and he was found hanging in his cell shortly after midnight.

HMP & YOI Parc was the subject of a damning HMIP inspection in September 2010, shortly after Shaun’s death, which found that healthcare services were not being delivered to an acceptable standard. G4S took over healthcare services that month and a decision was taken to close the inpatient unit.

Giving evidence during the inquest, Louise Jeory, employed as Healthcare Manager at the time Shaun’s death, described poor staffing, lack of training, lack of record keeping and low morale when she took up her post in June 2010. She admitted that the healthcare unit was “compromised and unsafe” at the time of Shaun’s death and admitted that a breakdown in systems and a lack of competence of staff had contributed to his death.

Ms Mackenzie of the Health Care Inspectorate Wales, described “chaos and crisis” within Parc’s Healthcare facility.  She concluded that Shaun’s death was “foreseeable and preventable” and that the provision of care and treatment by Parc to Shaun Beasley was “grossly inadequate” leading to a systematic failure to protect him from suicide.

Shaun’s family said:

Shaun was dearly loved by his family and his death has left a terrible gap in all our lives.  It is painful for us to hear that had Shaun received the care and treatment he should have done, he is likely to still be alive today.  We have been told changes have been made at Parc in the wake of Shaun’s death.  They come too late for us but we hope other families can be spared the pain and anguish we have had to go through.

Deborah Coles, co-director of INQUEST said:

 Shaun’s tragic death was an accident waiting to happen.   What is deeply concerning is that Parc’s healthcare was allowed to descend into such a state of chaos.  Shaun’s case raises startling similarities to the appalling death of Aleksy Baranovski at Rye Hill in 2006.  An inquest in 2009 similarly made damning criticism of the failures of systems, training and communication in the healthcare wing run by Primecare at the time of Aleksy’s death.  G4S took over running Rye Hill in 2008.  This begs the question, what control and accountability is in place when things go wrong with private contractors?  What must happen now is national scrutiny and learning to address these deficiencies.

 

The family is being represented by Stephen Webber of Hugh James Solicitors.

 

Ends