Death of prisoner with Learning Difficulties at HMP Wymott contributed to by neglect
On 19 November 2010 a jury at Preston Coronerâs Court returned a strongly-worded narrative verdict regarding the death at HMP Wymott of a 23 year old man who had learning difficulties, was faecal incontinent, and was known to have been bullied and had gambling problems (which amounted to other prisoners getting him to gamble on hopeless things such as whether the sun would come up tomorrow).
William Walters was put on the Adapted Sex Offenders Treatment Programme at the prison with insufficient support and on 14 September 2005, the day he was in the âhot seatâ (when it was his turn to disclose full details of his offending to a group of fellow prisoners) he hanged himself. During a 10 day Inquest in front of Dr Adeley, HM Coroner for Preston, the jury heard evidence that information was not passed on from one prison to another, or from prison healthcare to other relevant departments, and that officers who knew of Mr Waltersâ disabilities â in particular his incontinence and vulnerability to bullying â did next to nothing to provide him with a safe or decent environment.
The full verdict;
âWilliam Walters died from hanging which caused his death, and was contributed to by neglect.
William Walters was not cared for in a safe and decent environment in view of his disabilities whilst at HMP Wymott.
His attempts to highlight his problems were not effectively acted upon as evidenced by:
- Attempt at self-harm
- Request to suspend time on ASOTP course
- Request to move to I wing
Other contributing factors:
- Bowel problems and learning disabilities not recognised despite numerous opportunities
- Insufficient record keeping on official prison documents in view of self-harm, bullying, gambling and bowel problems
- Ineffective communication within the prison between the disciplines
- Recommendations following ETS course not actioned
- Participation on ASOTP course with insufficient or effective support outside of the group tailored for his specific needs
- No consideration of a more appropriate environment for his disabilities and needs.â
The verdict is an example of how jurys, properly directed, are able to assimilate large amounts of information and evidence received over a long period, and produce a meaningful verdict which properly holds the State accountable.
It is to be noted that the verdict did not conclude that Mr Walters committed suicide, as the Coroner carefully directed the jury that there were three primary findings open to them on the evidence. Either Mr Walters (a) killed himself intending to do so, (b) killed himself intending something else, or (c) died by hanging; roughly equating to suicide, accident, and open verdict as to intent. âNeglectâ was left to the jury on the Jamieson direction, and so constitutes a finding of gross failure(s) causally connected to the death.
After the verdict, the Coroner announced that he was making two Rule 43 recommendations and was intending writing to the Judicial Studies Board. The R43s relate firstly to the PSO (prison service policy) dealing with prisoners with disabilities, as the Coroner found that it is not compatible with the DDA 2005, as it appears to require self-disclosure of disability. Therefore it does not cover prisoners such as Mr Walters who cannot be expected to self-declare because of their disabilities. The R43 letter will also cover the system of transferring prisoners with learning disabilities, which should ensure there is a proper handover between establishments. This would normally be a role dealt with by social workers in the community, when a patient with disabilities is transferred between medical practices. In this case Mr Walters had been well cared for in HMYOI Lancaster Farms who recognised his needs and vulnerabilities, but there was no evidence of any handover when he reached the age of 21 and was transferred to HMP Wymott. The second R43 is to be directed to the Department of Health, recommending that they sort out the difficulties relating to the disclosure of information between prison healthcare and psychology.
The letter to the JSB (not a R43) will recommend that judges indicate in cases such as these that court reports should be disclosed to all relevant departments in the prison, where (as here) the sentencing judge recognises vulnerabilities which will affect the level of care required for the prisoner. The sentencing judge had indicated that the psychiatric and social worker reports should accompany Mr Walters through his prison progression, but in fact they were left unread on his Healthcare file and not shared with others involved with Mr Waltersâ care.