Inquest jury critical of care at Woodhill Prison

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The family of a man whose death in Woodhill Prison was ruled to have been an accident have said they are happy with the verdict but hoped lessons would be learned .

Kevin Scarlett, 30, was found hanged in cell 1.01 on May 22, 2013. He had used a bed sheet as a ligature which was tied up to the top bunk of the cell.

Following a three-day inquest an 11-strong jury ruled the death was an accident but said failings had occurred in Kevin’s care while he was in prison on remand for burglary.

The inquest heard Kevin had suffered a long history of mental health problems, having been diagnosed with schizophrenia and bipolar disorder, although doctors were later working to a diagnosis of emotionally unstable personality disorder.

He was a regular self harmer, and had made a number of serious attempts to kill himself.

During his time at Woodhill Prison he was placed on basic regime – which meant he had a number of privileges removed and spent up to 22 hours a day in his cell. He also had a note put on his door warning other prisoners not to talk to him.

After hearing lengthy evidence the jury concluded Kevin’s self harming and suicide was not properly assessed, that it was not appropriate for Kevin to be on basic regime, that it was inappropriate that he was the only person in a double room, that he should have been allocated to a safer cell and that he should have been subject to enhanced case management.

Coroner, Tom Osborne, said he was concerned by evidence he heard that HMP Woodhill did not have a tool to assess Kevin’s level of risk of self harm and suicide.

He said he would be bringing his concerns to the attention of NHS England and the National Offender Management Service in the hope that future deaths can be prevented.

Speaking outside the Civic Offices, where the inquest was held, Lee Jarman, Kevin’s step-brother, said: “We are happy with the conclusion and the jury’s response to all 0f the questions.Kevin was a loving son, brother and uncle and will be missed. Our main concern was that he was underestimated as being a low risk of suicide. If you look at the care history he tried to commit suicide before and he was hoping to be found on this occasion.

“If Kevin had been put in a safer cell then an assessment could have been done properly. Kevin’s death was avoidable.”

His mother, Patricia Jarman, of Hodge Lea, said: “It’s been harrowing, it’s been a long time while we have waited for this.

“Kevin was a very kind hearted person. He was a very loving, loyal son, brother, uncle and friend but he did have complex mental health needs which were underestimated and which resulted in this tragic accident. He will be deeply missed and always in our hearts and thoughts.

“It is important to remember, in these cases, that there is an individual involved, and they should not be treated as just one more difficult person who cannot be helped. I sincerely hope that if nothing else, that lessons will be learned.

“I am grateful to the coroner and to the jury who have clearly given a lot of careful thought to the conclusions they have reached.”