An inmate found hanged in his cell at Lewes Prison was let down by those responsible for his care, an inquest has heard.
Nathan Vaughan-Jones had been sentenced to 11 years in prison after admitting the manslaughter of his 63-year-old step-father Nigel Ross in Mill Lane, South Chailey, on March 29, 2011, on the grounds of diminished responsibility.
However, just a few months into his sentence, the 34-year-old was found dead in his prison cell.
An inquest into his death held at Eastbourne Town Hall reached a conclusion this afternoon (Friday, July 3). The ten-person jury unanimously agreed the death was suicide but included a number of failures they felt contributed to his death.
The jury’s statement read: “The deceased was a first-time offender. He suffered with chronic fatigue and depression. Evidence has shown he had difficulty coming to terms with living with his guilt and remorse over his crime, all of which were contributing factors in his death.
“We find failure to undertake an initial mental health interview after sentencing contributed to a lack of ongoing monitoring, which could have led to early intervention.
“While receiving support from the chaplaincy team, opportunities to open an ACCT document were missed. This omission was a contributing factor in the deceased’s death.
“The lack of response to the deceased’s letter to the governor was a contribution in the decline of the deceased’s mental state.
“Insufficient evidence in prison records showed prison staff were not meeting their duty of care to the deceased’s right to life. This lack of communication between different departments was detrimental to the deceased.”
Over the course of the five-day inquest, the jury heard how Mr Vaughan-Jones had felt “bullied” and “threatened” by other prisoners. He claimed to find inmates in his cell, going through his papers, and one even threatened to “cut” him.
While Mr Vaughan-Jones was moved to another wing of the prison, no formal note was made of the previous incidents, nor of his concerns regarding other prisoners.
Upon moving to another cell, Mr Vaughan-Jones was said to feel “isolated” and applied for a transfer to Lowdham Grange Prison, which had been granted.
The jury heard how he had appeared optimistic about the move, but had committed suicide before it had a chance to materialise. While there was no clear suicide note in his cell, a number of sealed envelopes were later found to contain letters to family members, clearly stating his intentions to take his own life, and even the manner in which he planned to do so.
In the letters, Mr Vaughan-Jones said he was convinced the investigation into his case had been re-opened but would not explain how he knew this. There was also a copy of a letter he claimed to have sent to the prison’s governor, but one the prison service insisted had not been received. In letters to his family, Mr Vaughan-Jones made reference to the fact he had not received a response to his letter and said how this had a negative effect on him.
During his time in prison, Mr Vaughan-Jones was never the subject of an ACCT - a prisoner-centred flexible care-planning system which is designed to reduce the risk of suicide and self-harm.
Any member of prison staff is able to open an ACCT if they have even the slightest concern about an inmate’s state-of-mind or safety. However, despite Mr Vaughan-Jones not coming out of his cell, not eating and apparently telling one member of staff he “can’t go on living like this”, no member of staff deemed it necessary to open an ACCT.
Coroner Alan Craze said: “This was a tragedy - almost a unique tragedy. I have never, ever yet dealt with a case where the character and the gifts of the deceased were so markedly different from the type of people he was to encounter when he got into prison.
“He was a kind, respectful, intelligent and honest young man who, in the words of many people, shouldn’t have been in prison.
“I cannot begin to understand how difficult things must have been for him. For his relatives, this is a devastating and life-changing tragedy.”
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