Jury finds that Stewart John Stanley, a prisoner on remand at HMP Exeter, died as a result of causative failings by prison staff

Stewart died on the 13 July 2020 at the Royal, Devon and Exeter Hospital, after having been found suspended in his cell by ligature at HMP Exeter in the early hours the day before. Following a two-week inquest, the jury found that the risk that Stewart might take his own life had not been properly appreciated, and that HMP Exeter’s processes, which were designed to reduce the risk of a prisoner taking their own life, had not worked appropriately in Stewart’s case. The jury concluded that both of these failures were probably causative of Stewart’s death. 

Stewart was remanded to HMP Exeter on 23 June 2020, where an Assessment, Care in Custody and Teamwork (‘ACCT’) plan was opened, due to low mood, anxiety and a previous suicide attempt by hanging. That plan was closed the next day.

On 4 July 2020, Stewart was assaulted by another prisoner whilst in the shower. Three days later, Stewart was moved to the same Wing as the suspected perpetrator.

On 9 July 2020, Stewart attempted to ligature in his cell, after expressing concerns to his family about his safety. A second ACCT was opened and Stewart was deemed to be ‘high risk’ and placed on to constant supervision in an anti-ligature cell, meaning a Prison Officer was to observe him at all times. Whilst on constant supervision, Stewart was noted by staff to be paranoid and erratic, and maintained that he was under threat from other prisoners.

On 11 July 2020, following an ACCT review in the morning where it was decided that Stewart’s risk had not changed and he needed to remain on constant supervision, a decision was taken to remove Stewart from his anti-ligature cell, to stop constant supervision and to place him onto 30 minute observations. The decision was made without input from healthcare staff in the prison, contrary to HMP Exeter’s policy. The jury found that this decision, to exclude those best qualified to appreciate Stewart’s risk to himself, probably led to his death.

Less than 10 hours later, Stewart was found by staff, having ligatured in his cell.

The jury heard evidence from Stewart’s family – who had contacted the prison on several occasions to express their concern about his safety and wellbeing – that he was a caring and loving person, and that they did not wish another family to go through what they had following Stewart’s death.

At the conclusion of the inquest, the Coroner paid tribute to Stewart and his family for their support of the organ donation process.

The family was represented by Christopher Johnson and Rachel Woodward instructed by Chanel Dolcy and Larry Lock of Bhatt Murphy Solicitors.

The other Interested Persons were the Ministry of Justice, Stewart’s ex-partner, Care UK, Devon Partnership NHS Trust, and Paul Cowell, former Head of Security and Operations at HMP Exeter.

The Coroner was HM Senior Coroner for Exeter and Greater Devon, Mr Philip Spinney.

For further enquiries about Christopher and Rachel, please contact Senior Practice Manager Melvin Warner.