Prison staff fail to respond to reports of noose in cell of suicidal man

At the time of his death, David Gray was an inmate at HMP Bullingdon. David was vulnerable. He had a history of severe traumatic brain injury and (perhaps consequential) mental illness. He had a history of serious self-harm and attempted suicide, including attempted suicide by ligature. When David moved to HMP Bullingdon, he was seen on occasions by a specialist brain-injury worker, but this service was withdrawn. Mental health services within the prison then agreed to take David “under their wing”, but they never saw him.  On 16 and 17 March 2019, David made multiple verbal threats to take his own life; David wrote three notes, threatening to take his own life; and David was said to have a noose in his cell. Prison staff and prison healthcare staff did nothing. David took his own life by hanging on the evening of 17 March. This week, a jury has identified myriad failings by prison staff and healthcare staff in the run-up to David’s death. The coroner indicated that he would write to HMP Bullingdon to raise concerns in relation to the management of prisoners with brain injury, and the procedure for handover of information between shifts.

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David’s family were represented by Chris Johnson instructed by Vicky Richardson and Alexandra Eldon of Hudgell Solicitors.