Prison staff criticised after inmate takes own life

Staff at HMP Nottingham were criticised in the coroner's report

A prison has been warned it needs to improve after an inmate took his own life.

Kevin McDonnell, 47, was incarcerated at HMP Nottingham when he died in his cell on 29 September 2022.

A jury at Nottingham Coroner's Court returned a narrative conclusion last month, noting how he had taken his own life and "a series of failings in his prison and health care" had contributed to his death.

Coroner Laurinda Bower issued a prevention of future death report to the prison.

The report said McDonnell "had a long history of mental ill health, paranoia and self-harm behaviours".

It added that 29 September was identified "as a trigger date when he might be more susceptible to self-harm and suicide on account of this being the anniversary of a relative’s death".

On 28 September there was "a failure by prison staff" to carry out a planned review, with staff on the wing "unaware" of the trigger date and others not knowing the inmate was under review.

'Failure to support'

On the morning he died, McDonnell "had appeared agitated overnight and had not slept at all", but the information "was not shared with day staff".

"There was a failure to provide [him] with the necessary support for his mental health in terms of therapy, medication review and psychiatric assessment," the report said.

Ms Bower also raised concerns over the way records of interactions with McDonnell were altered after the death.

A conversation history sheet for the day of his death was "amended by staff, under the supervision of a senior officer", though none of the recorded interactions were the appropriate level of checks.

"This tampering with evidence misled the Prison and Probation Ombudsman’s investigation, and only fully came to light during the inquest," she said.

"If post-death investigations are misled by inaccurate documentation that has been amended post-death, then the ability to learn from deaths in custody will be hampered.

"The preservation of accurate documentary evidence must be of paramount concern when a person dies in custody."

In 2018 HMP Nottingham was the first prison to be issued with an urgent notification letter by the government over concerns about conditions, which came after a number of prisoners took their own lives.

Following publication of Ms Bower's report, the Ministry of Justice said: “Since McDonnell’s death, HMP Nottingham has updated its practices so that every prisoner at risk of self-harm or suicide is overseen by a member of staff in line with national prison policy and we will consider any further changes required from the coroner’s findings.”

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