Jury concludes that Mark Jozunas died due to neglect

On 20 March 2021, Mark Jozunas took his own life in a segregation cell in HMP Chelmsford. He had a longstanding diagnosis of paranoid schizophrenia and was placed into segregation the previous night whilst he was experiencing a relapse of his condition.  

The bars across the windows in the segregation cell contained fabric remnants which were suggestive of previous ligature attempts inside that cell. In the days and weeks leading up to his death, Mark had displayed increasingly psychotic symptoms, he had attempted suicide, and he was visibly distressed by the first anniversary of the index offence. 

The jury found that a series of failings by prison and healthcare staff caused Mark’s death, including:

  • Prison staff failed to initiate an ACCT (self-harm prevention procedure) when Mark was placed into segregation, despite his heightened vulnerability and the state of the cell into which he was placed.

  • The health assessment performed by the nurse which deemed Mark fit for segregation was inadequate. The nurse failed to gather readily-available information about Mark’s mental health history and failed to get him the urgent medical attention that he needed. 

  • Prison staff failed to observe Mark properly whilst he was in segregation. Mark was supposed to be checked at least hourly whilst in segregation, and the jury concluded that the prison failed to carry out these checks.  

  • The prison psychiatrist “failed to review and optimise Mark’s medication despite requests made by Mark on multiple occasions. They failed to assess risk, review the care plan, and conduct multidisciplinary meetings.  They failed to provide basic medical care to Mark”. The jury considered that these amounted to “gross failings”. 

In response to the concerns raised by the family and the Jury, the Coroner decided to report the psychiatrist in question to the General Medical Council. 

Frederick, instructed by Katie Wilkins and Fiona McGhie of Irwin Mitchell, acted for Mark’s family.

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.