Coroner concludes that Anthony Paine died due to neglect
On 19 February 2018, Anthony Paine took his own life in a cell in HMP Liverpool. He had a longstanding diagnosis of schizophrenia and had received an enhanced package of care (Care Programme Approach) whilst he was in the community. However, he did not receive a face-to-face mental health assessment or risk assessment during the four and a half months at the prison.
On 17 and 18 February, prison staff observed Mr Paine displaying bizarre behaviour and having self-harmed. They requested an assessment by healthcare staff who reported that they were unable to do so because of the poor condition of the cell.
On 19 February, with Mr Paine’s condition having worsened further, prison staff increased Mr Paine’s observations to one per hour and requested an urgent mental health assessment. The mental health triage nurse decided to assess Mr Paine that afternoon as part of a multidisciplinary ACCT review. Staff moved Mr Paine’s cellmate out of the cell around midday, leaving him alone.
Mr Paine was seen by a prison officer attempting to ligature at around 2pm. The officer did not remove the ligature from him. When the officer returned at around 2:45pm, Mr Paine was found to have ligatured. Mr Paine was pronounced dead shortly afterwards after being taken to hospital.
Following Mr Paine’s death, there was a criminal investigation into the prison officers’ conduct. Two members of prison management were charged, one with gross negligence manslaughter, and another with breaches of health and safety legislation. The inquest was resumed after the trial was aborted before reaching its conclusion.
The Senior Coroner concluded that:
- Mr Paine's mental healthcare was not equivalent to that which he would have received in the wider community in multiple respects. In particular, there was a lack of mental health assessment by the Community Justice Liaison Team managing the transfer into the prison estate; a distinct lack of health assessment inside the prison, which failed to identify his vulnerabilities, history of self-harming, and suicidal ideation; a lack of input from mental health professionals in to his ACCT reviews; and a lack of an assessment by a psychiatrist to review his medication and the deterioration in his health.
- The cell in which Mr Paine died was “unfit for purpose”. The cell was described by a prison nurse as the “worst cell she has ever seen”, and was described by the PPO report as having been in an “appalling condition”. The walls and ceiling were painted in a non-standard dark colour, the lights were not working, and the windows were broken. There was no evidence that Prison Staff carried out daily fabric checks as they were required to do or that management took any action to address these glaring problems. All this was contrary to PSI 17/2012.
- There were repeated failures by prison staff to manage Mr Paine’s risk of suicide and self-harm, notably the decision to leave Mr Paine alone in his cell from 18 February (the day before his death), leaving him with a ligature in his cell on 19 February, and the decision not to increase his frequency of observations over the weekend of his death, all notwithstanding that he was visibly distressed and was witnessed attempting a serious act of self-harm.
The Senior Coroner further found that: “there were serious failings, and in the case of mental health care in prison, serious systemic failings which more than minimally contributed to this tragic fatal event.” He concluded that these were “basic gross failures” which had “directly contributed to this fatal event – such as to amount to neglect…”.
For coverage related to the case, see ITV, BBC, London Evening Standard, Liverpool Echo, The Independent.
Frederick Powell, acted for Mr Paine’s family, instructed by Elaine Macdonald of Broudie Jackson Canter. Frederick specialises in healthcare-related inquests and human rights law. For more information about Frederick, contact our Senior Inquests and Inquiries Practice Manager, Melvin Warner.
