Jury find serious failings by both prison staff and healthcare staff at HMP Swansea contributed to the self-inflicted death of Robert Lee Evans

An inquest into the death of Robert Lee Evans concluded on Thursday 13 October 2022 after the Jury found serious failures by prison and healthcare staff at HMP Swansea probably contributed to his death. Assistant Coroner Kirsten Heavens issued a prevention of future deaths report as she had serious concerns that further avoidable deaths could happen if preventative action is not taken.

Lee’s family was represented by Shanthi Sivakumaran of Doughty Street Chambers. She was instructed by David Pearson of Broudie Jackson Canter.

Lee was a much loved member of the family. His mother, siblings and aunt attended the Inquest at Swansea Coroner’s Court. Lee had a long history of anxiety and depression and alcohol addiction. Two days before his death, he had been recalled on licence after two weeks in the community. The Jury heard that when he was returned to HMP Swansea:

• An ACCT was not opened although there were several risk factors and triggers present to raise concerns about Lee;

• Lee was provided medication for alcohol withdrawal by Nurses under a patient group directive and a formal prescription was not issued;

• Lee was not prescribed medication for his anxiety and depression that he had been receiving regularly in prison before his release two weeks before;

• Lee was placed in a cell alone on his request. The cell had bars on the window which were known ligature points.

• On the night that Lee died, Lee was locked in his cell from 16:30 until he was found at after midnight. No checks had been carried out on Lee during that period of time.

Lee returned to HMP Swansea on 12 January 2018. The next day he was seen on CCTV speaking animatedly to Prison Officers following a visit to the medical hatch. The Prison Officers did not respond to Lee and soon after he was seen on CCTV posting a letter. The letter, found after his death, had a note that he believed his medication had been stopped. Lee was locked up in his cell at around 16:30 the same day. He was found soon after midnight having tied a ligature from the bars of the window in his cell. No checks had been carried out on Lee between 16:30 until he was found after midnight.

The Jury concluded that:

• the prison staff failed to adequately assess Lee’s risk of suicide and self-harm and

• the prison staff and healthcare staff failed to take appropriate steps to safeguard Lee while he was in prison custody by not opening an ACCT and communicating information about his prescription to him;

• The Prison did not have an adequate system of checks in place for Lee in light of the fact that he was undergoing alcohol detoxification and on the induction wing in the early days of prison;

• The Doctor responsible for Lee’s healthcare failed to properly review Lee’s medical notes and prescribe him anti-depressant medication;

• The Doctor responsible for Lee’s healthcare failed to properly prescribe lee detoxification medication

The Jury concluded that the systems and processes in place at HMP Swansea probably contributed to the failure of the healthcare staff in reviewing all the records.

On 4 January 2018, 9 days before Lee died, HM Inspectorate of Prisons published a strongly critical report condemning HMP Swansea’s ‘complacent and inexcusable’ approach to the safety of vulnerable prisoners and failing to respond effectively to high levels of self-harm and suicides of new prisoners.[1] HM Inspectorate of Prisons reported that there had been four self-inflicted deaths in HMP Swansea within a week of arriving. The next report by HM Inspectorate of Prisons issued in 2020 found that there had been two further self-inflicted deaths since the last inspection.

Assistant Coroner Kirsten Heavens issued a prevention of further deaths report as she was concerned from evidence she heard that a future death was possible. Her concerns were:

1. Lee had suspended himself from bars of a window in the induction unit. It was well known by prison staff and recognised in Ministry of Justice policy and in HMP Swansea Prison policy that the very early days are a particularly high-risk time for prisoners particularly those on remand or recalled on licence. She was concerned that despite awareness of this risk, there were exposed bars on the windows in the induction unit in HMP Swansea. There was a safer cell on the induct unit where the whole window unit has been replaced with plastic material which can be slid to allow prisoners to obtain air from outside the cell. Prisoners are not kept on the induction unit for a significant period of time but are in the induction unit during a vulnerable time in custody.   

2. She heard evidence from two prison officers who were seen to speak to Lee on HMP Swansea CCTV. They were the last members of prison staff Lee spoke to before his death. At all stages into the investigation into Lee’s death (prisons and probations ombudsman and coronial) these witnesses have stated that they were unable to assist with what Lee was saying to them hours before his death. She was concerned that immediately following Lee’s death and the following day that these highly material witnesses (who were on duty) were not spoken to, did not attend a hot or cold debrief and were not asked to make a first account of events when matters were fresh in their minds. These witnesses did become known to the PPO. As a result, her investigation into Lee’s death was significantly hampered. She was therefore concerned that lessons may not have been fully learnt from the circumstances of Lee’s death.