HMP Nottingham: Prison staff failings 'factor in inmate's death', jury finds

Ben Ireson arrived in HMP Nottingham on 16 October, 2018, but was found dead in his cell on 13 December that year

An inmate who killed himself while being held in a problem-plagued prison was failed by staff, an inquest found.

Ben Ireson was found hanged in his cell at HMP Nottingham on 13 December 2018.

A jury said "missed opportunities" to monitor the 31-year-old's mental health, "poor record-keeping" and other factors "more than minimally contributed" to his death.

Mr Ireson's brother said the family was "devastated to hear the shocking evidence of how badly Ben was failed".

"We were told that improvements have been made at the prison since Ben's death, but we question how effective these can really be and whether lessons will actually be learned," he said.

"We are concerned that other families will end up in our position."

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The inquest heard Mr Ireson - who was born in Luton and had a reported history of anxiety and mental health issues - arrived at the Category B site in October 2018 while being held on remand before a trial.

He told his mother he wanted to kill himself in phone calls that should have been monitored, and though he was put on a mental health programme he was removed from it "prematurely".

The governor of HMP Nottingham said it was the worst prison he had seen in his 30-year career when he arrived in July 2018

Prison staff failed to consult all information management systems, and in some cases staff did not know Mr Ireson or his medical history.

The inquest heard he had moved cells several times, and though he requested a cellmate he was left on his own in the days before he died.

He was last seen alive on the evening of 12 December, and his body was found during checks the following morning.

'Woefully short'

The inquest heard about long-running problems at the prison - which was the first in the UK to be issued an urgent notification letter in January 2018 - over self-inflicted deaths.

Phil Novis, who took over as governor in July 2018, told the inquest there had been "failings at all levels" and apologised to Mr Ireson's family.

He said the prison had improved following the death, and the inquest heard there have been no suicides at the jail since Mr Ireson's.

Laurinda Bower, assistant coroner for Nottinghamshire, said said she was "shocked" that prison staff giving evidence at the inquest had not read reports by the Prisons and Probation Ombudsman (PPO) into Mr Ireson's death.

Saying Mr Ireson was failed by "the very systems that should have been in place to protect him", she said staff "failed to follow well-established national guidelines" and "fell woefully short" of what was expected.

She said the fact no further self-inflicted deaths had occurred and "assurances" made by Mr Novis for further improvements meant she would not issue a prevention of further deaths report, but warned: "No-one wants to slip back to the chaos and uncertainty that existed at the end of 2018."

Governor Phil Novis said he recognised there was more to do at HMP Nottingham