An inquest found neglect by prison and mental health services led to Tony Paine’s suicide at HMP Liverpool.
An inquest found neglect by prison and mental health services led to Tony Paine’s suicide at HMP Liverpool.
Prison Neglect Contributed to Inmate Suicide Weeks Before Release
Anthony Paine had mental health issues, and a nurse admitted they failed him. He was found hanging in his cell. Mr. Paine was due for release in two weeks. His mother, Janet, spoke to the ECHO, and her son told her, “Don’t let anyone get away with it.”
The coroner, André Rebello, wrote an inquest stating the prison service, the Ministry of Justice, and an NHS trust should have done more to keep Mr. Paine safe. Mr. Rebello shared more findings, noting that one staff member felt the system failed and another said he needed therapeutic contact. The staff were very upset by Mr. Paine’s death.
The inquest found serious failings and systemic issues in mental health care that contributed to his death. Mr. Rebello stated that these failings amounted to neglect. Mr. Paine struggled with self-harm, misused substances, and had mental health problems, including schizophrenia. Outside prison, he had enhanced care.
He got a keyworker who could not see him due to a heavy workload during his time at Walton prison. Prison staff knew about his self-harm and started suicide prevention on February 1, 2018. He reported being bullied and using psychoactive substances.
He was moved to a different wing and downgraded on February 16. He then moved to a new cell and received a new cellmate at this time. He stayed in his cell all weekend, and staff noticed strange behavior and cuts on his arms. Staff thought he was using substances, but healthcare could not reach him because the cell was dark.
Observations were three times a day and night; subsequently, staff checked him every hour and requested a quick mental health review. Staff moved his cellmate around midday after checking on him twice before this. He said he felt fine each time. An officer found him distressed around 2 PM with a noose.
The officer did not take the noose but asked for it upon returning. Mr. Paine claimed he threw it out the window, but the officer later found him unresponsive. The prison service and the Ministry of Justice accepted the findings from the Prison Ombudsman, which indicated staff should have removed the noose sooner.
The Ministry of Justice agreed the cell was inadequate with dark walls and no working light, potentially hurting his mental health. A clinical review showed poor communication between his drug worker and the mental health team, a main problem found in the review.
The mental health care was worse than care outside the prison. Mr. Paine did not get an adequate service, and his caseworker never saw him face-to-face. Mr. Paine did not get a mental health assessment despite escalating substance use and stopping psychiatric medications, a failure the team didn’t notice.
Mr. Paine did not see a psychiatrist due to long waiting lists, and the healthcare team canceled two appointments while he canceled one. All notes said he could see the duty team. He was referred on the day of his death, but they decided not to see him due to a system error contributed to the decision which was against a history full of substance abuse. The lack of face-to-face contact was due to workload, and nurses felt they failed him because they had large amounts of work to deal with.
Mrs. Paine remembered her son fondly, describing him as lovely and honest, finally stating she could put him to rest.
Anthony Paine had mental health issues, and a nurse admitted they failed him. He was found hanging in his cell. Mr. Paine was due for release in two weeks. His mother, Janet, spoke to the ECHO, and her son told her, “Don’t let anyone get away with it.”
The coroner, André Rebello, wrote an inquest stating the prison service, the Ministry of Justice, and an NHS trust should have done more to keep Mr. Paine safe. Mr. Rebello shared more findings, noting that one staff member felt the system failed and another said he needed therapeutic contact. The staff were very upset by Mr. Paine’s death.
The inquest found serious failings and systemic issues in mental health care that contributed to his death. Mr. Rebello stated that these failings amounted to neglect. Mr. Paine struggled with self-harm, misused substances, and had mental health problems, including schizophrenia. Outside prison, he had enhanced care.
He got a keyworker who could not see him due to a heavy workload during his time at Walton prison. Prison staff knew about his self-harm and started suicide prevention on February 1, 2018. He reported being bullied and using psychoactive substances.
He was moved to a different wing and downgraded on February 16. He then moved to a new cell and received a new cellmate at this time. He stayed in his cell all weekend, and staff noticed strange behavior and cuts on his arms. Staff thought he was using substances, but healthcare could not reach him because the cell was dark.
Observations were three times a day and night; subsequently, staff checked him every hour and requested a quick mental health review. Staff moved his cellmate around midday after checking on him twice before this. He said he felt fine each time. An officer found him distressed around 2 PM with a noose.
The officer did not take the noose but asked for it upon returning. Mr. Paine claimed he threw it out the window, but the officer later found him unresponsive. The prison service and the Ministry of Justice accepted the findings from the Prison Ombudsman, which indicated staff should have removed the noose sooner.
The Ministry of Justice agreed the cell was inadequate with dark walls and no working light, potentially hurting his mental health. A clinical review showed poor communication between his drug worker and the mental health team, a main problem found in the review.
The mental health care was worse than care outside the prison. Mr. Paine did not get an adequate service, and his caseworker never saw him face-to-face. Mr. Paine did not get a mental health assessment despite escalating substance use and stopping psychiatric medications, a failure the team didn’t notice.
Mr. Paine did not see a psychiatrist due to long waiting lists, and the healthcare team canceled two appointments while he canceled one. All notes said he could see the duty team. He was referred on the day of his death, but they decided not to see him due to a system error contributed to the decision which was against a history full of substance abuse. The lack of face-to-face contact was due to workload, and nurses felt they failed him because they had large amounts of work to deal with.
Mrs. Paine remembered her son fondly, describing him as lovely and honest, finally stating she could put him to rest.