Early morning roll call failed to spot prisoner had killed himself in cell at Shropshire prison, inquest told

A jury of 10 men and women concluded that Neil Stuart Bott, aged 54, died at Stoke Heath Prison, near Market Drayton sometime between 9pm on December 19 and a routine roll call at 7am on December 20.

The inquest at Shirehall, in Shrewsbury, on Wednesday, was told that a brief check through the single cell's door observation panel at 5.45am had "failed to notice" that he had died.

An ambulance was called following the 7am check and paramedics were able to conclude quickly that the patient had died with no chance of resuscitation.

Senior Shropshire and Telford Coroner John Ellery was told that he was not alive at that time. The inquest also heard that a CCTV system covering the inside of the prison, including his cell door, had recorded his light going on and off after the evening lockdown.

As a result a Prisoner and Probationary Ombudsman (PPO) report was carried out to investigate, as they are with all prisoner deaths.

They found that Bott had been jailed for two years and eight months for arson in January 2020 after an incident in his bedroom at house in multiple occupation (HMO) in Brookside, Telford, where he had been living for some time. He was released on licence one year later but recalled to HMP Hewell, in Redditch, after four days.

Mr Ellery told the hearing that Bott, who was born in Singapore, then started to refuse to take vital medicines and limited his intake of food and water.

Bott had been told he was being transferred back to Stoke Heath, and he objected to that. He had issues with the healthcare provided there and refused medicines, food and water.

But the inquest was told that the PPO made a number of recommendations for both HMP Hewell and HMP Stoke Heath to carry out.

The PPO found that the handover from Hewell to Stoke Heath did not involve staff telling each other that Bott had been refusing to take vital medicines and food. So called "refusal policies" were not followed.

Three recommendations were made in the PPO report, the inquest heard. These included staff reviews of prisoner health, creating tailored individual care plans, and recording a prisoner's care needs and discussing them with staff at the prison they are being taken to. Healthcare staff should also be familiar with policies.

In Bott's case the inquest jury was told that there had been "no indication of his suicide risk increasing after he had been taken off an Assessment Care and Custody Teamwork (ACCT) plan".

Mr Ellery told the jury that the "facts are not in dispute" and all the evidence pointed to Bott intending to kill himself with no expectation of being found.

"There is one conclusion to record, that it was suicide," said Mr Ellery.

Coroners also have the power to issue Prevention of Future Death notices, which require authorities including prisons to take action to prevent such incidents.

Mr Ellery said he was satisfied that both prisons had taken action based on the PPO recommendations. HMP Stoke Heath is mainly and adult prison, with about a quarter of the inmate population being aged between 18 and 25.

Selina Fyffe, Stoke Heath's head of safer custody, said that when prison staff carry out roll calls they are "not just a headcount but a welfare check." The prison has some 780 inmates and 154 prison officers, with an additional number of healthcare staff.

Mrs Fyffe said that they have 14 people on the ACCT assessment regime, which "not high" in national terms. She said that Bott had left no note, had received no visitors during his time in prison. Members of the family were not present at the inquest.

Mrs Fyffe said procedures have been re-iterated to staff, detailing the procedures they have to follow.

"If someone is suicidal they have to open an ACCT and have to follow procedures assessing the vulnerabilities and support mechanisms," she said.

"We retrained everyone in July 2021, and everyone has awareness training," she said.

Bott had been on an ACCT but he had been deemed safer and this regime was closed. Two months later he killed himself.

"There was no evidence of an increased level of risk but we don't just close an ACCT and forget it," she said.

The coroner asked Ruth Minnis, who was representing the Shropshire Community Health NHS Trust, and Heather Aspinall, who was representing the Ministry of Justice, whether all the actions required had been carried out. Speaking over an internet link, they both confirmed they had been.

> Whatever you're going through, you can call Samaritans any time, from any phone for FREE.

Call 116 123

or write an email for a response in 24 hours.

Sometimes writing down your thoughts and feelings can help you understand them better.

Email jo@samaritans.org