Prison failings contributed to inmate's death
The failure of the prison service to pass on information about a Shropshire young offender's mental health contributed to his death, an inquest has ruled.
Staff at HMP Stoke Heath in Market Drayton were not sent a document revealing that 18-year-old Nicholas Saunders was at risk of self harm or suicide and prison officers on his wing were also not aware that Mr Saunders had made a previous attempt to kill himself.
A jury in Wem yesterday ruled Mr Saunders had killed himself but both the failings had contributed to his death.
Mr Saunders, a bartender from Albert Gardens in Sundorne, Shrewsbury, was serving a 14 month sentence for possession of an offensive weapon in a public place at HMP & YOI Stoke Heath, near Market Drayton, when he died on April 2 last year.
He had served four months of his sentence at HMP Wood Hill near Milton Keynes before transferring to HMP Stoke Heath in February last year.
Shropshire coroner Mr John Ellery said he would highlight the failings. Talking about the at risk document, he said: "Wood Hill didn't send it, Stoke Heath didn't receive it."
Mr Ellery also said he would give 'careful thought' to a request by the family to ask that light fittings should be changed in standard cells so they are embedded into the ceiling. Mr Saunders had tied a ligature to the hanging light in his single cell.
The inquest heard that Mr Saunders believed he was not going to see his mother on Mother's Day, the day after his death, because of a mix-up with visitor orders.
By a majority of eight to one the jury decided the error over the visitor booking also contributed to Mr Saunders' death, but concluded that more investigation was needed into the cause of the error.
