Stephen Bird: Jury concludes ‘numerous failures’ contributed to death in prison
Stephen Bird had only been in prison for four days when he took his own life. He was experiencing alcohol withdrawal, suffered multiple physical injuries from falls, and was severely confused. He was also unable to contact his family, despite repeated attempts. Hours earlier, he had been placed on an ‘ACCT’ – a procedure to safeguard prisoners at risk of self-harm – and moved to the healthcare unit, but these steps failed to keep him safe.
Stephen had arrived at HMP Altcourse late on 4th September 2023 after a period in police custody. He had suffered for many years with alcohol dependence syndrome and was at the ‘peak’ of alcohol detox when he arrived at prison.
During his few days in prison, he experienced repeated falls from his top bunk and suffered multiple physical injuries. He injured his head, his right elbow and his left heel. Whilst he was seen by different nurses, and appeared in pain, he was never given any pain medication.
To make matters worse, due a mistake when he arrived at the prison, Stephen was never able to contact his family. He repeatedly tried to call his mother and older sister, but the calls were blocked by the prison system as ‘unauthorised numbers’.
On 8th September 2023, staff had serious concerns about Stephen’s presentation. He appeared severely confused and made a comment that he was going to hurt himself. The inquest heard evidence from Stephen’s cellmate, who stated that he had said he had ‘had enough’ and decided to end his life. The cellmate rang the cell bell and informed a prison officer about this, and told them to remove ligature items Stephen had on his possession, but they were ‘not interested’.
Stephen was eventually seen by a mental health nurse who was very concerned about his presentation and arranged for him to be taken to the inpatient unit to be assessed. However, after arriving there by wheelchair, he was never assessed by a doctor or physical health nurse, but was left alone in a cell for approximately 3.5 hours.
Whilst an ACCT was opened due to his suicidal ideation, the middle manager wrote the ‘immediate action plan’ before going to see Stephen. He did not complete the plan in conjunction with Stephen, did not read it to him, show it to him, or ask for his input in any way. He simply went to Stephen’s cell and asked him ‘to sign the paperwork’. This was despite Stephen having expressed an intention to end his life, and continuing to appear confused and disoriented.
After extensive questioning by Matthew, the middle manager admitted that a ‘better’ action plan should have been put together to keep Stephen safe.
The jury therefore concluded that “The deceased was able to take his own life due to numerous failings in communication and due to inadequate completion of records”.
Matthew Turner represented Stephen’s family at the inquest, instructed by Charlotte Halsted and Phoebe Pratt of Broudie Jackson Canter.
The Coroner was HM Assistant Coroner for Liverpool, Mr David Lewis. The other Interested Persons were the Sodexo, Practice Plus Group and Mersey Care NHSFT.
Matthew is a specialist in deaths in custody. He regularly exposed serious state failures and, notably, has secured 10 neglect verdicts in different inquests since December 2021.
You can contact the Samaritans for free on 116 123 or from prison on 0845 450 7797.
