A jury inquest has concluded that “failure to provide adequate staff” contributed to a prisoner’s suicide in June 2017. Lee Parish, 40, had a history of depression and had been identified as a suicide and self-harm risk. Mr Parish was meant to be checked every 30 minutes by staff but on the day of his death, staff shortages meant that he was not checked for over three hours. Mr Parish was found dead in his cell by another prisoner who alerted prison staff.

Ten days before his death, Mr Parish had attempted suicide. Despite this attempt, prison staff did not hold a suicide and self-harm review meeting and the healthcare department was not informed.

A prison officer told the inquest that the prison was in “dire straits”. Andrew Langridge, The Head of Operations at the jail, said staffing levels were less than half of what they should have been which meant the prison was “unable to sustain the level of support required for people like Lee”. He accepted that there had been multiple failings in the prison’s care of Mr Parish and that lessons had been learnt.

In a statement Lee’s family said: “The last year and a half has been a struggle for us as a family. We are devastated by Lee’s death, it has changed our lives forever. The inquest process has been challenging and sometimes traumatic, but we are satisfied with its outcome and the recognition of the failings that contributed to Lee’s death. We are grateful to the staff at HMP The Mount for their honesty, openness and their acceptance of the failings in his care. We hope that the lessons learned will result in better care for vulnerable prisoners like Lee, and that other families will be spared the trauma we have endured.”

Deborah Coles, Director of the charity INQUEST said: “The jury at the inquest found a catalogue of failings contributed to Lee’s death. Despite being on hourly observations as part of suicide and self-harm monitoring procedures, he was not checked on for three hours and eventually found by another prisoner. His death was entirely preventable.

“Time and time again, inquests expose lamentable failings in the processes to identify and care for people distressed in prison. Yet such dangerous practices and systemic failings persist.

“Prisons are inherently toxic and unhealthy environments. Until there is a dramatic reduction in the use of prison, a redirection of resources into community alternatives, as well as a clear and enforceable system of accountability which protects prisoners, then needless deaths and harms will continue.”

Lee’s family were represented by James Robottom who was instructed by Cormac McDonough of Hodge Jones & Allen.

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