HMP Bullingdon staff criticised over inmate's death

Coroner Darren Salter said he would contact the prison governor to call for improvements

Prison and healthcare staff should have done more to prevent an inmate with a brain injury and history of self-harm from killing himself, a jury found.

David Gray, 54, was found dead in his cell in HMP Bullingdon's healthcare unit on 17 March 2019.

He regularly threatened others and said he would harm himself in an attempt to get what he wanted, prison staff said.

A Prison Service spokesperson said: "Our thoughts remain with Mr Gray's family and friends."

Oxford Coroner's Court was told a prison healthcare worker was unaware of Gray's extensive history of self-harm and thought he was threatening her when he said he would harm himself and mentioned a ligature.

He was found hanged in his cell by a mental health nurse at about 21:40 GMT.

'Errors and omissions'

In his conclusion, senior coroner Darren Salter said prison and healthcare staff failed to leave adequate details in handovers between shifts or escalate concerns about Gray's behaviour.

He added there were "errors and omissions" in the provision of the inmate's care in the days prior to his death.

Mr Salter confirmed he would be contacting the prison governor to call for improvements in the management of prisoners with brain injuries.

A prison service spokesperson said they would "consider" the coroner's verdict and respond "in due course".

The inquest heard Gray was a "lodger" in the prison's healthcare unit because there was nowhere else suitable for him.

A former head of healthcare at HMP Bullingdon, Christopher Law, said he had opposed Gray's transfer from HMP Portland in Dorset but it happened anyway.

Healthcare workers and prison officers disputed each others' claims of why an assessment for prisoners found to be at risk of suicide or self-harm was not undertaken on the day Gray died.

The healthcare staff said one was not discussed, while prison officers said the healthcare staff had told them starting an ACCT (Assessment, Care in Custody and Teamwork) was unnecessary.

Mr Salter said the Ministry of Justice had accepted an ACCT should have been opened on the day of Gray's death.