A culture of 'debts, threats and violence' coupled with serious failings at Woodhill Prison in Milton Keynes led to an inmate committing suicide in his cell, an inquest jury heard.
Darren Williams, 39, was the first of four men to die at the jail this year and his family say his death was "completely preventable."
The inquest heard how drugs were widely available at Woodhill and these led to prisoners being in debt to each other.
Darren had a long history of drug abuse, debt accrual and mental ill health and had seriously self-harmed on four occasions he was so worried about the threats of violence towards him.
On each occasion suicide and self-harm procedures (known as ACCT) were started and he was moved to another wing within the prison. However, the inquest heard he was not offered victim support services and no action was taken when Darren named those who were threatening him.
The jury found failures relating to information sharing, ACCT processes and the handling of reports made by Darren explaining the threats he was facing due to the money he owed.
They also found Darren’s applications to move to the vulnerable prisoner’s unit were either not documented or incorrectly considered.
In a detailed narrative, the jury found ‘consistent failure' to follow applicable processes and protocols, and said the support provided to Darren was ‘inadequate and lacking' in key areas.
The coroner will now be making a report to Woodhill's Governor in a bid to prevent future deaths. It will focus on the need for members of healthcare to attend ACCT reviews and for previous ACCTs to be reopened when the same concerns recur rather than starting the process afresh.
The jail is currently in the process of downgrading from a local remand prison to a Cat B training prison. But the most recent inspection of HMP Woodhill found the prison is ‘still not safe enough’.
Darren’s sister, Carri Williams, said after the inquest: “It’s very important to us as a family that Darren be seen as the person he was and not just a number in the system. He was a son, brother, grandson, uncle and a good friend to many. As a family we believe that his passing was completely preventable, which makes our loss even more unbearable. This has impacted our lives in a terrible way and every day we suffer and question the ‘what ifs’. We now have to visit a cemetery on a regular basis to even feel close to him and stare at mud and ornaments. It’s just awful and unfair. He should have been kept safe.”
Darren's family were represented by lawyers through the charity INQUEST. The charity's spokesman, Selen Cavcav, said: “It is chilling that the circumstances and failures of Darren’s death are so familiar. How many more people must lose their life as a result of these deplorable failures in the prison’s duty of care?
"Darren’s death is one of four self-inflicted deaths in Woodhill Prison this year. As deaths in custody spiral and recommendations from inspections, investigations and inquests are ignored, a vicious cycle goes into tailspin. The current system for implementing change is not fit for purpose. A national oversight mechanism is urgently needed, to ensure official recommendations are systematically followed up and to prevent another family from experiencing this loss.”
The family's lawyer, Jo Eggleton of Deighton Pierce Glynn solicitors, said: “We learnt during the inquest that the re-categorisation of Woodhill prison from a local remand prison to a category B training prison which was originally planned for March 2018 has begun at last. No explanation has been provided for the delay, during which eight more men have died there. None the less it will come as a great relief to the still grieving families I have represented over the years."