A jury has found that a man who suffered from mental health problems was let down by the care he received at HMP Woodhill.
Jack Portland, 29, died on December 27, 2015 while on unescorted community leave, his absence went unnoticed for an hour and 30 minutes after he was due to return.
The police were not called for over two hours and his family were never informed that he was missing.
The jury concluded on Friday, after a lengthy inquest at Buckinghamshire Coroner’s Court, that there had been a range of failures by the public bodies responsible for keeping Jack safe when in custody and when sectioned under the Mental Health Act in hospital.
In a tribute to Jack, his family said: “One of the last things Jack ‘wrote’ was ‘life’s short, don’t be lazy’, good advice son, and I hope we have done you justice.”
Popular at school and described by his friends and family as lively and outgoing, he had struggled with drug addiction.
The jury heard that Jack had deliberately shoplifted in desperation, in the belief that he could get clean in prison.
Instead he was exposed to widespread availability of the drug ‘Spice’ and developed psychotic symptoms for the first time.
Failings were found by the jury in the discharge and resettlement process at HMP Woodhill.
The jury also found four categories of failure at the Whiteleaf Centre (Oxford Health NHS Foundation Trust), where Jack was a patient at the time of his death.
Last year HMP Woodhill recorded the highest number and highest rate of self-inflicted deaths across the entire prison estate.
The tribute to Jack continued: “Losing a loved one is very difficult, losing a child in tragic circumstances is a life time sentence in regret, knowing the life experiences we all enjoy have been cut short for him, wishing things were different.
“The culmination of the inquest process and the recognition of Jack as a person, exhibiting and experiencing a constellation of health concerns, demonstrated by the jury’s finding that there were failings in his care, is some relief to us.
“However we are saddened that the experience of people with impaired mental health, coupled with addiction, is continuing to be misunderstood, a stigma applied and their care mismanaged.
“It’s evident that society still has a long way to go in treating everyone with equal concern. The family will continue to try and effect a positive change for people in need of support and understanding.”