'Missed chance' to prevent death of inmate in cell
BBCOpportunities were missed to assist an inmate who was found dead on the day he was due to be released from prison, an inquest heard.
Nigel John Keenan, 62, was discovered in his cell at HMP Haverigg in Millom, Cumbria, during a routine count by prison staff in the early hours of 13 March last year and pronounced dead shortly after by paramedics.
A jury at Workington Coroners Court concluded he had died by suicide.
Jurors said "heightened stress and worry" ahead of his release, driven by difficulties in finding suitable housing for Keenan as he was a sex offender, "probably" contributed to his death. The coroner said he plans to write to NHS England to raise concerns over mental health staffing.
The inquest was told Keenan had been sentenced to five and a half years in prison in June 2022 for offences including engaging in sexual activity with a child.
The nature of his crimes made the search for suitable housing more difficult due to restrictions imposed on registered sex offender, jurors were told.
Keenan had hoped to live with his partner, but social services told them the father of her daughter would have to be informed of Keenan's offending for this to happen. This led to the breakdown of the relationship.
A number of other housing options were not deemed suitable for Keenan and it was only eight days before release that it was confirmed he could live with his brother.
In its conclusion, the inquest jury said: "It's probable the heightened stress and worry of [arranging housing] contributed more than minimally to his death."
They added another "possible contributing factor" was the "stress and anxiety" Keenan experienced due to his relationship breakdown and also pointed to "missed opportunities" to help him.
A month before release Keenan had reported having suicidal thoughts.
The inquest was told he believed they stemmed from a new medication he had been given for nerve pain and once the medication was changed he reported feeling better.
Health care staff deemed him not to be at risk and, although he had several meetings with staff, no formal mental health monitoring was put in place.
Evidence heard during the three-day inquest showed that although mental health teams from Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) are available at Haverigg, they were not commissioned by NHS England to operate at weekends.
Coroner Robert Cohen said he found this "surprising" and he would be formally writing to NHS England to raise concerns in a prevention of future deaths report.
The document is used by coroners to highlight issues they believe need to be addressed to prevent deaths in similar circumstances.
'Confused' claim
Days before his release, prison staff had received intelligence suggesting Keenan had made a threat to "do something that week that would shock the prison".
Staff believed Keenan, whose behaviour was described as "manipulative", intended to abscond from prison and flee abroad.
When questioned by staff, he was reported to be "confused", denied ever making comments about doing something that would shock the prison and the matter was not pursued further.
But the jury said this reported threat could have been considered in the context of his earlier suicidal thoughts.
They said: "A simple question with no further exploration could have been a missed opportunity."
They added Haverigg had "demonstrated to have various avenues of support" for prisoners, some of which Keenan had refused to take up, including help targeted at those about to be released.
Support and advice can be found via the BBC Action Line.
