Insufficient staff numbers and a lack of compassion could have contributed to the death of a prisoner at HMP Highpoint, an inquest has found.
On May 23, 2014, David Shane Smith, formerly David Shane Rogers, was transferred from HMP Chelmsford to a double cell at Highpoint, in Stradishall, where he was found hanging later that night.
His death was confirmed at West Suffolk Hospital, in Bury St Edmunds, the following morning.
An inquest into his death opened in Bury on August 15.
On Wednesday the jury found that Highpoint should have opened an assessment, care in custody and teamwork (ACCT) document – a way of raising concerns about prisoners who are deemed to be at risk – for David earlier and had not filled it in fully and appropriately when it did.
It found that these and other matters, including insufficient staff on duty, a lack of training, insufficient staff awareness of protocol, failure checking the observation log in the wing diary and a lack of compassion, may have contributed to his death.
Born in Harrow, Middlesex, David lived in Harlow, Essex, before prison and, though he had a history of substance abuse, had been on a voluntary program of methadone reduction and took his last dose on May 19, 2014.
The inquest heard that David was convicted of supplying drugs but had been looking forward to getting out of prison and being free from drugs.
His mother, Julie Smith, told the jury a letter from David, written three days before his death, ‘was upbeat and full of jokes’ and ‘said he wanted to change and not get into conflict with the law again’.
The inquest heard that on his induction night at Highpoint, David had made frequent requests for a single cell and repeated threats to self harm.
He also asked to speak to a ‘listener’ – prisoners trained by the Samaritans to offer confidential peer support – and, on being told no-one was available, made repeated requests to phone the charity’s helpline.
His cell mate Warren Sampson was unable to give evidence to the inquest as he has since died in another prison but the jury was told of information he gave when interviewed, including that David made a ‘small scratch’ on his wrist, claimed to have swallowed a razor blade and wrapped a towel around his neck that night.
Suffolk coroner Dr Peter Dean said of Mr Sampson, who reported waking up to find David hanging from his bed: “He was absolutely certain that Mr Smith didn’t mean to kill himself. He thought it was attention seeking behaviour that had gone wrong.”
In delivering the jury’s findings, Dr Dean said it had reached a unanimous narrative conclusion that David died from hanging by a ligature he deliberately placed around his neck, but could not be sure from the evidence whether it was an impulsive act, an act carried out in an attempt to move to a different cell or whether he intended the outcome of his actions.
In a statement issued through justice charity INQUEST following the conclusion of the inquest, David’s family said: “Our son was calling out for help, but no-one helped him and he should not be dead.”
“We got the justice that David deserved,” they added.