Coroner calls for action after prisoner’s suicide

A coroner has called for a government review into health screening, medical care, supervision and training in jail after recording a verdict of suicide on an inmate who hanged himself in Norwich Prison.

Norfolk coroner William Armstrong said he would be contacting justice secretary Ken Clarke and health secretary Andrew Lansley to raise a number of issues following the death of Jonny Riley, 28, who he said had been “failed” by the prison system.

Mr Riley, of Bagge Road, King’s Lynn, died on March 12, 2008 on his first night inside the Knox Road jail after being transferred from Peterborough Prison.

The inquest, at the Assembly House, Norwich, had previously heard that earlier on the day he died, Mr Riley had spat at a prison officer. He also threatened to smash up his cell and harm himself.

Despite documents listing his history of self-harming, this information was not referred to and no risk assessment was carried out.

Mr Riley, a heroin addict, was also going through withdrawal, which resulted in volatile behaviour. He had requested medication which was not delivered.

The jury of nine offered their condolences to Mr Riley’s family and said there had been failures at both Peterborough and Norwich prisons.

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At Peterborough, there were failures in the distribution and completion of documents, as well as inadequate protocols and procedure relating to his transfer to another jail. There was also an omission in administering Mr Riley’s prescribed medication the day before he died, the jury found.

At Norwich, there was also a failure to distribute, complete and open documents, and a lack of adequate investigation into Mr Riley’s medical history and “presentation”, leading to a failure to prescribe or administer any opiate substitute.

The jury also found there had been inappropriate use of the hatch on his cell door and that no observations were made on him between 4.15pm and 4.54pm. He died at 5.20pm.

“The physical management of Mr Riley’s fits was appropriate but the follow-up was not. In conclusion, we feel that the above contributed to the death of Mr Riley,” it found.

Coroner Mr Armstrong said: “Jonny Riley was failed in certain respects by a system that was there to contain him but also to protect him.”

The inquest had revealed significant shortcomings relating to the assessment of his medical needs, the clinical management of his drug addiction, the lack of continuity in his medical care and the failure to protect him from self-harm, he said.

“Although his action in taking his own life may have been impulsive, he clearly acted in the context of his frustration and anger at not getting appropriate medical attention, which was his right.

“It is commendable that lessons have been learned as a result of this tragedy, action has been taken and there are now in place more robust systems for addressing these issues.”

Among the issues Mr Armstrong plans to take up with ministers are the need to improve reception health screening, continuity of care, prisoner escort record procedures and staff training relating to suicide and self-harm.

After the hearing, Mr Riley’s partner Sherene Briggs said: “We’re pleased with the result. We feel it was the right verdict.”

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