10th August 2016

Monday 4 July - Tuesday 2 August
Before Senior Coroner Dr Peter Dean
Counsel for the family:  Catherine Oborne
Represented by:  Broudie Jackson Canter Solicitors

A jury has found that inadequacies in care at HMP Blundeston were probable causes of the death of Sonny Robertson, 40 years old from Liverpool, in a critical narrative conclusion with neglect. Failures by a number of other public authorities were also found to have been possible causes of his death following the inquest.

There were a number of failings by the prison service, including lack of appropriate care, lack of communication between disciplinary, healthcare, pharmacy and IDTS (Integrated Drug Treatment System), which were all probable causes of Sonny’s death. In addition to a failure to provide adequate mental health support, insufficient staffing levels, inadequate training, inadequate out of hours health care support and first aid training all added to being probable cases of his death.

Sonny was remanded in custody at HMP Blundeston, which was closed in 2014 and did not have 24 hour health care. The inquest into his death heard that Sonny had a long history of medical problems including a reliance on medications such as those to help him with sleep and anxiety. An ACCT was opened when his self-harming caused significant blood loss and he was taken from prison to James Paget Hospital on 2 October 2013.

In hospital, he was prescribed anti-anxiety medication, which was not taken from him when he returned to prison that evening as no healthcare staff were present at night. It was acknowledged during the inquest that this was a mistake on the part of accompanying officers. He didn’t have any of his medication left in the morning, but a manager still closed his ACCT on 3 October as he was not considered to be at further risk of self-harm.

On 4 October, Sonny’s 2 week prescription of sleeping medication ended. He threatened to self-harm and as a result, an ACCT was reopened and a letter drafted to the hospital asking them not to provide him with medication in anticipation of him harming himself. That evening, Sonny self-harmed again and lost further blood. An ambulance arrived over an hour after he was found and Paramedics said he was in danger of hypovolaemic shock. A code red was not called at any time by prison officers.

Sonny was again taken to James Paget Hospital where he asked for, but didn’t receive, further anti-anxiety medication. He needed a blood transfusion, but refused treatment after he was denied the medication. It was put to many witnesses that Sonny could have been offered the option to stay in hospital over night for observations instead of being sent back to a prison with no 24 hour health care, but the evidence was that no one had even considered this as an option. He went back to the prison, but no written instructions were given to the prison staff about symptoms or signs of hypovolemic shock to look out for other than that he would be in ‘very serious trouble’ if he were to bleed any more.

Sonny was held in the segregation unit so he could be observed but the duty governor was not contacted at all during the night in relation to this or the events of the night, which the inquest heard should have happened. Shortly after his return, Sonny reopened his wound and asked to be taken back to hospital. There is conflicting evidence as to whether he collapsed at this point. The night orderly officer decided it was not necessary and did not seek medical advice or contact the duty governor.

Over the course of the night, Sonny asked for medication and to go back to hospital. He was given water and blankets. He woke at 3am and showed symptoms which could be attributed to hypovolaemic shock, such as light headedness and incontinence. However, the two staff on the unit did not seek medical advice, discuss taking him to hospital or contact the night orderly officer. Neither was aware of the symptoms of hypovolemic shock nor that Sonny was in danger of it.

On 5 October 2013 at about 6am, Sonny Robertson was found unresponsive in the segregation unit at HMP Blundeston. Paramedics attempted to resuscitate him without success and he was pronounced dead at 6.44am. His main cause of death was hypovolaemic shock.

The inquest into his death heard extensive evidence relating to the inadequate standard of care he had received in the segregation unit. The jury unanimously found that Sonny died as a result of the unintended outcome of self inflicted arm wounds made whilst a serving prisoner at HMP Blundeston in an attempt to obtain additional medication to which neglect contributed. The neglect found was the result of a number of contributing factors in respect of both actions taken and omitted. The Coroner is drafting a Regulation 28 report.

Dale Robertson, Sonny’s brother, speaking for the family said:
‘It has been an extremely difficult 3 years for our family, waiting for this inquest, so that all the facts and circumstances surrounding Sonny’s tragic death could be explored and brought to light.  We feel that justice has now been done as the jury’s conclusion reflects and publicly records the neglect and gross failings in Sonny’s care leading up to his death’.   

Chris Topping, the solicitor representing the family, said:
‘It is at least some consolation for the family that the gross failings by the prison service on the night of Sonny’s death have been acknowledged by the jury in this inquest as probably causative of his death. The wholly shocking disregard for his wellbeing here must be learnt from and not repeated. Our hope is that the Coroner’s report will assist with this learning process. However no one can do anything to bring Sonny back to his family or compensate them meaningfully for the inhumane way in which he died.’

Full jury findings:

  • It was not appropriate that Sonny was not given a full mental health assessment at HMP Blundeston.
    ● Appropriate steps were not taken to remove razor blades from Sonny at any stage after 2 October 2013. This was a probable cause of his death.
    ● A code red should have been called in response to the incident on 4 October 2013
    ● There was an inappropriate delay in the ambulance being able to leave the prison on 4 October 2013
    ● The communication between hospital staff and prison staff at the James Paget Hospital was inadequate.
    ● Sonny should have been returned to hospital on the night of 4 / 5 October 2013.
    ● The acceptance from a Prison Governor that there was a failure to provide Sonny with appropriate care after 3am on 5 October was a probable cause of his death. 
    ● Lack of communication between disciplinary, healthcare, pharmacy and IDTS (Integrated Drug Treatment System) staff was a probable cause of his death. 
    ● Failure to provide adequate mental health, psychosocial and emotional support or therapy other than medication was a probable cause of his death. 
    ● Insufficient staffing levels and inadequate training, resulting in failures to follow protocol and procedure was a probable cause of his death. 
    ● Inadequate out of hours emergency health care support and/or mandatory contingency first aid training of disciplinary staff was a probable cause of his death. 

INQUEST has been working with the family of Sonny Robertson since 2013.  The family is represented by INQUEST Lawyers Group members Chris Topping, Leanne Dunne and Alice Stevens from Broudie Jackson Canter Solicitors and Catherine Oborne of Garden Court Chambers.