Prison neglect led to tragic death of a young man
from various sources – Nov 2018
submitted by – Tippa Naphtali
Updates listed at the foot of this item
On 16 December 2015, in the course of an acute mental health crisis, 25-year-old Dean Saunders stabbed a family member and, while trying to stab himself, injured another family member. The police subsequently charged him with two counts of attempted murder. The next day, he was remanded to HMP Chelmsford. The prison was alerted that he was at high risk of suicide and that there was a report that recommended he should be transferred to hospital under the Mental Health Act.
Dean instead was admitted to the inpatient unit at Chelmsford and staff began Prison Service suicide and self-harm prevention procedures, known as ACCT. Initially staff agreed they would constantly supervise him until a psychiatrist conducted a full assessment.
Dean was found dead in the prison on 4 January 2016 after electrocuting himself. It was his first time in prison. The charity INQUEST said that; “Dean showed signs of acute mental ill health in the days before his imprisonment. He was taken from his home by the police on 16 December 2015 after an incident during which he tried to take his own life.
“At the police station, he was not detained under the Mental Health Act and transferred to hospital. Instead, he was charged and subsequently transferred to HMP & YOI Chelmsford.”
Mark Saunders, Dean’s father, said the family had questioned his placement in prison from the outset. “Obviously our concerns were that he needed help and medication, we needed to find out what was going on,” said Mr Saunders. There was no proper medical structure there [in prison] to help him. We were lied to and mislead all the way through. We were devastated.”
Nigel Newcomen, the Prisons and Probation Ombudsman said, that those involved in Dean’s care felt he should have been in a mental health facility rather than prison. “I am also concerned that there appears to have been some confusion at Chelmsford about the process for transferring mentally ill prisoners to hospital, which meant that an opportunity to transfer Mr Saunders in December [of 2015] was missed. Sadly, the criminal justice system did too little to protect this very vulnerable man.”
In January 2017 an inquest jury today found that ‘neglect had contributed to the death Dean after being taking into custody when he was suffering a severe mental health crisis. The jury also found that Dean and his family were “let down by serious failings in both mental health care and the prison system” and said that Care UK, the private company that runs healthcare at the prison, “treated financial consideration as a significant reason to reduce the level of observations”, despite repeated warnings of Dean’s state of mind.
The inquest concluded that Dean had killed himself while the balance of his mind was disturbed and that the cause of death was “contributed to by neglect”.
Deborah Coles, Director of INQUEST, said; “Dean Saunders, a young father in serious mental health crisis, should never have been in prison in the first place. His death was entirely preventable. The responsibility for his death lies with a system that criminalises people for being mentally ill.
“As a society, we should not accept that deaths such as Dean’s are inevitable: they are not. Time and again, we hear the empty words ‘Lessons will be learned’. Without action and accountability, nothing will change. Until this government properly invests in mental health provision and stops the use of prison for people in mental health crisis, these tragic and needless deaths will continue.”
In March 2017 Justice Secretary, Liz Truss, met Dean’s relatives at HMP Whitemoor in Cambridgeshire and said she had asked them to be involved in policy-making. She also announced plans for 2,000 new prison officers and improved training.
Dean’s father, Mark, warned that others will die unless minsters urgently improve care behind bars. Mark said; “I looked back through ten years of investigations into suicides and the same failings are repeated, there are clear patterns there. I told her that I was angry, because if something had happened many deaths and inquests ago maybe we wouldn’t be here now. I’m angry on that side. “But now I know the failings I can’t walk away. I can’t walk away and let someone else die and I don’t want Dean to have died in vain.”
Don’t let my son’s death be in vain, pleads dad
1 March 2017
Dean Saunders death: Prison ombudsman finds ‘weaknesses’
22 January 2017
The Independent investigation into the death of Mr Dean Saunders a prisoner at HMP Chelmsford (pdf file)
Published in 2015