23rd October 2012

The Inquest into the death of Tony Doherty before HM Assistant Deputy Coroner for West London concluded on 17 October 2012.

The jury found that Tony took his own life, and his death was contributed to by systemic deficiencies. They stated the following deficiencies contributed to Tony’s death:

1)    Not collating, sharing and using information about suicide/ self harm consistently;

2)    Not carrying out night patrols in accordance with the prison policy;

3)    The failure of the cell call sounder alarm to activate; and

4)    Not responding promptly to the cell call light.

The Jury felt these deficiencies reflected potential weaknesses in the training and management of staff.

Tony, who was 22 years old, was found hanging in his cell in the segregation unit at HMP Wormwood Scrubs on 3 December 2010.

On the night prior to his death CCTV showed that checks of prisoners on the segregation wing were not completed as required by the staff member on duty, and despite Tony ringing his cell at 11.55pm this remained unanswered when he was found at 2.37am, over 2 ½ hours later.

Evidence was heard at the Inquest that Prison Officers had been able to disable the cell bell audible alarm for more than 18 months prior to Tony’s death, and by the date of his death it had been permanently damaged. Despite checks of the system purportedly having to take place every day no repairs were requested. One of the Governors called to give evidence for the Prison Service accepted that this was “totally unacceptable”.  Another Governor accepted that the deficiencies were the result of “mismanagement”.

Some of the critical evidence in the Inquest had only been disclosed to the family on the day before the Inquest started and had never been disclosed to the Prisons & Probation Ombudsman.

Tony’s mother Theresa Doherty expressed the wish that following the verdict changes would be made at HMP Wormwood Scrubs to prevent further deaths.

Tony’s family were represented by Clair Hilder from Hodge Jones & Allen LLP and Jonathan Glasson of Matrix Chambers.

Solicitor Clair Hilder commented following the verdict;

“A series of failings were found which contributed to Tony’s death. This case raises concerns about not just the care Tony received but others in prison. Despite extensive investigations into the events of Tony’s death the prison were unable to explain whether this was an isolated incident or if other staff members were also failing to complete night patrol checks and respond to cell bells.  As one of the jurors asked the Governor, after an incident when a prisoner died showed a 100% failure rate why didn’t the prison consider investigating other nights to see whether the same failure rate was found?”

Deborah Coles, co-director of INQUEST said:

“In light of the rise in self-inflicted deaths in prison this case gives cause for serious concern. With ever-decreasing resources we hope the findings of this inquest send a message to all prisons that corners cannot be cut when dealing with vulnerable prisoners. This death may well have been prevented had there not been a blatant disregard for policy and procedure.”