Jury find serious failings contributed to self-inflicted death of Lance Clark whilst on remand at HMP Chelmsford

The jury in the inquest into the death of Lance Clark, 53, concluded finding serious failures by prison and mental healthcare staff contributed to his death. Lance’s family was represented by Tom Stoate of Doughty Street Chambers’ Inquests and Inquiries Team.

Lance was a much-loved father and family man. He had a long history of anxiety, depression and self-harm. During nearly two weeks of evidence the inquest jury heard that, in his four months at HMP Chelmsford, Lance self-harmed in the same way on 14 occasions using a razor blade or a sharp item, and was taken to hospital for treatment on eight occasions due to the severity of his self-harm injuries.

The jury heard:

  • Lance did not have a formal mental health review, and received virtually no help in managing his stress. He did not receive any intervention or treatment from IAPT (counselling) or Full Circle (substance misuse support) despite referrals from the prison psychiatrist on the one occasion (in August 2019) that Lance’s case was discussed;

  • Lance was not managed under enhanced ACCT procedures, which would have involved senior prison managers and ensured all relevant support was available for Lance. His ACCT case manager told the jury he had not heard of the enhanced ACCT procedure, and the Head of Healthcare at the time had never heard of Lance at all;

  • The Prisons and Probation Ombudsman (PPO) found that, as a result of the issues with the ACCT, more junior staff “were largely left to manage the complex problems [Lance] posed without adequate support”.

  • No-one discussed trying to involve Lance’s family in the ACCT process, and his family were not told that he had been repeatedly hospitalised after self-harming. Lance had no input at all from his allocated key worker, and an email about possible support for him from a prison psychologist went unanswered.

  • Despite Lance’s history of self-harm, neither prison nor mental health staff discussed Lance’s access to razors during ACCT case reviews. A Prison Service safety briefing in April 2019 which required that access to razors must be discussed at ACCT case reviews was not circulated to any prison or mental health staff.

  • An External Agency Investigation Request was submitted by Broomfield Hospital raising concerns around Lance’s access to razor blades, following frequent attendances at hospital with cuts inflicted by razor blades. HMP Chelmsford responded that no action was required.

  • No preventative care or support was provided to Lance, he did not receive any 1:1 time with a mental health nurse throughout his time at HMP Chelmsford, and no mental health plan or risk management strategy was put in place when Lance’s ACCT monitoring was stopped on 22 October 2019.

Lance was on remand during his time in HMP Chelmsford, and he repeatedly told prison and mental healthcare staff that he was stressed about his upcoming trial which went into the court’s “warned list” (meaning it did not have a fixed date).

On the morning of 28 November 2019 Lance was dismissed from his job as a wing cleaner after an incident the previous evening. Lance had repeatedly said his job enabled him to keep busy and reduced the time he spent alone in his cell, “spiralling” in negative thoughts. Lance immediately self-harmed by cutting his neck and, despite attempts at resuscitation, died that morning.

The jury concluded that prison and mental healthcare staff did not manage Lance’s risk of self-harm appropriately, which contributed to his death (including the failure to manage Lance under the enhanced ACCT process; the failure to implement an April 2019 safety briefing regarding prisoner access to razor blades and to discuss razor blade management at Lance’s ACCT case reviews; the way in which the dismissal of Lance from his wing cleaning job was handled; and the failure to adequately risk manage Lance’s probability of self-harm in the weeks prior to his death).

Lance’s was one of 14 self-inflicted deaths at HMP Chelmsford since 2016. The full inspection of HMP Chelmsford by HM Inspectorate of Prisons prior to Lance’s death (in May and June 2018) raised numerous concerns around how prisoners at risk of self-harm and suicide were managed. Inspectors found repeated recommendations from the Prisons and Probation Ombudsman had not been implemented, including poor assessment and management of prisoners’ risk of suicide and self-harm. More recent inspections have continued to highlight these ongoing concerns.

Tom Stoate of Doughty Street Chambers’ Inquests and Inquiries Team was instructed by Sam Hall of ITN Solicitors and supported by INQUEST.

INQUEST provide further detail about Lance’s case here.