An inquest jury sitting before HM Assistant Deputy Coroner for Northamptonshire, Tom Osbourne, today concluded that a catalogue of serious failings at the privately-run HMP Rye Hill caused or contributed to the death of 23 year old Michael Bailey who was found hanged in the segregation unit of the prison on 24 March 2005.
The jury concluded that the prison had failed in relation to every single aspect of Michael’s care that they had been asked to consider and that there was a “failure on the part of all staff to take responsibility for ensuring Michael Bailey’s safety”.
During the five week inquest, distressing evidence was heard about the severe deterioration in Michael’s mental health in the six days prior to his death. Michael, who had previously been described by all as a confident outgoing person, began to exhibit severe symptoms of psychosis, often crying uncontrollably, stating the walls and demons were speaking to him and telling staff at the prison he was ready to die.
Michael had written a detailed farewell note to his family and on one occasion walked around the exercise yard naked for two hours reciting the Lord’s Prayer.
The jury found that both prison and medical staff:
- failed to undertake an adequate mental health assessment;
- failed in their communication about his condition and care needs;
- failed to recognise the serious nature of his condition;
- failed to move Michael out of the segregation unit into healthcare when it became clear that he was at risk;
- failed to place him in a safe cell;
- failed to do all that could be reasonably be expected to prevent Michael hanging himself.
During the inquest the jury had heard that, despite a suicide and self harm monitoring form (F2052SH) being opened for Michael, key events were not recorded in it and the document was rarely read by staff. Observations required to keep Michael safe, which were supposed to be carried out six times an hour, did not take place and staff admitted to routinely falsifying these records. Indeed, when Michael was discovered motionless behind his cell door on the 24 March, an officer was instructed to falsify the watch records before going to provide assistance.
The jury also criticised the lack of trained and experienced staff, the lack of effective management and fundamental systems failure in dealing with suicide and self harm.
Deborah Coles, co-director of INQUEST, said:
“The shocking circumstances of Michael Bailey’s death, the first of three controversial deaths at the privately-run HMP Rye Hill, highlight both an appalling breakdown in procedures designed to protect life and uncaring and inhumane treatment of a vulnerable man. However, what is more concerning is that this represents not just a series of shameful individual failures, but a fundamental failure by the Prison Service to ensure that privately-run prisons are safe and meet acceptable standards for those in their care.”
Michael’s mother Caroline Bailey commented:
“Over the past few weeks, I along with Michael’s family and friends have endured hearing the details of the painful and dreadful last days of my dear son’s life.
We have listened as staff blamed each other as to why nothing was done to alleviate Michael’s suffering as he cried out for help. If just one of those involved had done their job properly, Michael could still be with us. They, each and every one owed Michael a duty of care and they failed him time and time again. I do not know how they can live with themselves.”
Michael Bailey’s family were represented by INQUEST Lawyers Group members barrister Leslie Thomas of Garden Court Chambers, instructed by Nogah Ofer of Hickman and Rose Solicitors.