A coroner ruled neglect led to Tony Paine’s suicide in HMP Liverpool, after years of his mother’s fight for answers.
Tony went to HMP Liverpool in 2017 and received an 18-month sentence for affray and endangering the public. His mom thought he was having a psychotic episode at the time of the incident.
Tony was found hanging in his cell in 2018, just two weeks before his release. He died at Aintree Hospital, and the family fought for recognition of prison failures. They wanted the prison system to acknowledge Tony’s risk and felt more should have been done to protect him
The coroner decided Tony died by suicide, and that prison and mental health service failures contributed to his death. Two officers faced manslaughter charges, but a court acquitted them in 2023.
Speaking at the courthouse, Mrs. Paine said she feels like she can rest now, after seven very hard years. Her health suffered during this time, and she has waited a long time for closure.
Her son wrote to her, “Don’t let anyone get away with it.” She feels she did him proud by pursuing the case.
Tony had self-harm, substance abuse, and mental health issues, including schizophrenia. Outside, he had a care program, but he only received a mental health keyworker in prison. The keyworker was unable to see him due to a very heavy workload.
The coroner said prison staff started suicide prevention on Feb 1 after Tony harmed himself and said he was being bullied. He was then moved to a new wing and to basic regime on Feb 16, which involved a new cell and a new cellmate.
Because of the basic regime, they stayed inside all weekend, during which time staff noticed Tony’s strange behavior and that he had cut his arms. They suspected he used drugs, but healthcare staff could not see him. The cell was dark, and his suicide watch stayed the same: three checks a day and three more each night.
Staff increased checks before Tony’s death, checking him every hour and requesting an immediate mental health check. They moved his cellmate at noon. When staff checked on Tony twice, he stated he felt fine. An officer found him distressed at 2 PM with a noose around his neck, but did not take it.
The officer returned at 2:45 PM and asked for the noose. Tony claimed he tossed it out the window, but when the officer came back again, Tony was unresponsive.
The prison and Ministry of Justice accepted findings from an investigation that prison staff should have taken away the noose immediately and used de-escalation methods.
The investigation highlighted his cell as dark and unacceptable, with dark paint on the walls and ceilings and no working light. The Ministry admits the cell condition may have negatively impacted Tony, even if it was not the main cause.
Lancashire Care NHS ran mental health services at the prison, but a review stated communication was lacking between Tony’s drug worker and the health team. An integrated care plan was needed.
Tony’s mental health care did not meet the standards he received outside prison, and he did not get proper service. His keyworker never saw him in person, and he lacked a health assessment or risk assessment.
He misused substances, missed medications, and self-harmed, but the team did not spot it and did not think Tony had an active case.
He never saw a psychiatrist due to long waits. Two appointments were canceled, one which he canceled himself. His keyworker said he could see the duty team, but he never did due to an error on the system. Reviewing full records could have helped to see his issues escalating, so he could get seen the day of his death.
The inquest concluded pressures caused the key worker to lose the contact, and staff felt that the service failed Tony.
A staff member thought Tony would have lived under another care plan, and others felt they let him down.
The coroner said Tony died by suicide with neglect, with the prison and healthcare failures directly leading to his death, and that mental healthcare had systemic failures.
Mrs. Paine said her son was a good, kind, and honest person, and described him as a loving son. She finally feels like she can rest now his case has ended.
The family lawyer stated neglect played a factor in his death because the prison failed Tony. He was very vulnerable with a diagnosed mental illness, but his care was not good.
He stayed in a dark cell and never saw a psychiatrist or a keyworker. The lawyer hoped the conclusion hopefully brings his mom some comfort now, so she can start rebuilding her life.