An inquest into the death of Ben Ireson at HMP Nottingham has found that prison staff failings contributed to the 31-year-old's suicide. The jury concluded that missed opportunities to monitor his mental health, poor record-keeping, and other factors 'more than minimally contributed' to his death on 13 December 2018.
Mr Ireson, who had a history of anxiety and mental health issues, had been on remand at the category B prison since October 2018. The inquest heard he told his mother in phone calls that he wanted to kill himself, but those calls were not properly monitored. He was placed on a mental health programme but was removed 'prematurely'. Staff failed to consult all information management systems and some did not know his medical history.
The court also heard that despite Mr Ireson requesting a cellmate, he was left alone in the days before his death. He was last seen alive on the evening of 12 December and was found hanged during checks the next morning. Phil Novis, who became governor in July 2018, apologised to the family and acknowledged 'failings at all levels'.
Assistant coroner Laurinda Bower expressed shock that prison staff giving evidence had not read reports by the Prisons and Probation Ombudsman into Mr Ireson's death. She said staff 'failed to follow well-established national guidelines' and 'fell woefully short' of expectations. However, noting no further suicides at the prison since and assurances from the governor, she declined to issue a prevention of future deaths report.
Mr Ireson's brother said the family was 'devastated' by the evidence and questioned whether lessons would be learned. HMP Nottingham had been the first UK prison issued an urgent notification letter in January 2018 due to concerns over self-inflicted deaths.
