Man who abused babies died after ‘misadventure’ behind bars
APAEDOPHILE who abused babies aged less than six months old died days after a “misadventure” in custody, an inquest jury has concluded.
The inquest into the death of Jared Perry at Pontypridd Coroners’ Court heard evidence about the events in the run-up to Perry’s death at the Princess of Wales hospital in Bridgend on Sunday, November 3, 2019.
The 32-year-old had been located unresponsive in his cell at HMP Parc Prison, Bridgend, at around midday on Wednesday, October 30, 2019, and did not regain consciousness. It was heard that Perry was taken to hospital where he remained in a coma before dying due to the complications of hanging.
A prison officer told jurors he “should have removed” an item from Perry’s cell which the prisoner later used to harm himself. The jury found a failure of prison staff to observe
Perry, a delay in his transfer to a secure mental health unit, and a failure to remove the item from his cell all contributed to his death.
In January 2019 Swansea Crown Court heard how Perry abused both male and female children before he confessed his crimes to the police in a bid to clear his conscience. Perry, of Llanilar, Aberystwyth, admitted 10 counts of indecent assault and sexual assault on a child under 13.
Perry abused the youngsters – some just months old – in a series of opportunist attacks, the criminal court heard. He was described as an “extremely high risk” to children and was handed a sentence of 17 years comprising 10 years in prison and an extended seven-year term on licence.
The jury inquest heard evidence from 26 witnesses in total, 10 of whom provided statements for the coroner, Graeme Hughes, to read out and 16 of whom gave evidence remotely or in person. Jurors how Perry had existing mental health difficulties prior to his conviction. His mother Tracey Perry said when he was eight years old the family discovered he had been abused – something which she said had a “huge impact” on him.
He was diagnosed with paranoid schizophrenia and prescribed antidepressants at the age of 17 which he took on and off because he “didn’t like taking medication”.
Ms Perry described how she had hoped prison would rehabilitate him, adding: “My family had forgiven him and were prepared to bring him back into the family and help him [when released].”
But the inquest heard how Perry’s mental health deteriorated in prison with his mother saying he “really suffered with his mental health” at HMP
Parc. Dr Rose Marnell, a GP at the prison who is part of its primary health care team, said Perry spent most of his time at the prison on an ACCT – Assessment, Care in Custody, and Teamwork – which is the care planning process for prisoners identified as being at risk of suicide or self-harm.
Prior to his death it was heard Perry had been put in a safer custody unit and subjected to increased observation of five times an hour which included the use of in-cell CCTV while one of the checks had to be in-person. The court heard on September 10, 2019, a doctor assessed Perry and said in a report he felt he presented as psychotic and needed to be transferred to a secure psychiatric unit.
But the doctor’s report was sent too late to the relevant team and it was also in the wrong format therefore the process could not continue and Perry’s transfer was delayed. When answering questions from G4S advocate Emma Zebb regarding how long it should take for someone to be referred to one of these units, Dr Marnell said: “You would hope it would be within two weeks.”
The inquest, which opened on Monday, March 18, and concluded on Wednesday, heard Perry was due to be transferred on November 4 to Cwm Seren secure unit, which falls under Hywel Dda University Health Board, but he died at 3.50pm on November 3 before this could happen.
“There has to be sufficient evidence to satisfy you had there not been a delay in the transfer process and on balance of probabilities the outcome for Mr Perry would likely have been different,” the coroner told the jury.
The inquest also heard evidence from former prison officer Ricky Boon who had cleared out Perry’s cell, while Perry was out of it, in the hours before he was found unconscious on October 30. He was carrying out an “accommodation fabric check” which Lee Burridge, the prison’s operational manager, explained to the inquest was supposed to take place every day and was a “cursory process”, taking a minute or two, to look for and remove any obvious risks – to security, escape, or selfharm – from prisoners’ cells.
The court heard the last time this had been done for Perry’s cell was October 28 but did not take place on October 29. The jury was shown the CCTV footage of Mr Boon entering
Perry’s room at around 10.44am on October 30. He appeared to clear general rubbish then pick up an item on Perry’s desk before putting it back down and leaving the cell. He told the inquest he didn’t remove the item because he believed it was Perry’s “comforter” but added: “I should have removed it.”
Coroner Mr Hughes then referred to a G4S statement Mr Boon had given on November 5, 2019, days after the incident, where he had offered up a different explanation as to why he picked the item up and then put it back down. Asked by the coroner if there was a “particular reason for that” Mr Boon said he couldn’t answer that question.
The coroner then referred to an interview Mr Boon had given with the Prisons and Probation Ombudsman (PPO) three or four months later when he told investigators he “didn’t see the significance” of the item or “any danger” associated with it leading him to put it back down. The coroner said: “You didn’t mention in that explanation to the PPO what you mentioned today in relation to your judgement of the item being a comforter.”
Mr Boon replied: “I can’t honestly tell you why I didn’t mention that at the time,” adding: “At no point did I ever think Perry was going to selfharm or attempt to take his own life.” The court heard Perry had not committed any previous acts of self-harm nor expressed any suicidal ideation and that other members of staff also didn’t consider Perry to be at acute risk of self-harm in the days leading up to the incident with a mental health nurse having even assessed him at 11am on the day itself and noting there were no acute concerns for him.
South Wales Police detective Alexander Waite, who reviewed Perry’s in-cell CCTV after he died, said on 11.26am on October 30 “Jared is seen to pick up [the item] from the table and then go into the area underneath the camera by the door and out of view”. That was the last time, before he was located, that Perry was seen alive, the inquest heard. Prison officers entered Perry’s cell at 11.52am after they couldn’t se him on CCTV and then spotted his feet through he observation hatch. Perry left no note nor did he have a mobile phone in his cell.
The inquest heard another prison officer, Robert Petrie, was tasked with carrying out observations on Perry in his cell on October 30. He told the jury he had undertaken observations of Perry at 11.28am and 11.41am and said though he had not seen Perry on CCTV he had heard him “shouting and kicking his door” and so from this concluded he was still alive.
The court heard two other prison officers did not recall Perry shouting or banging his door that morning but one said it was not uncommon for inmates to bang their doors. Meanwhile Mr Burridge told the inquest that it was expected if a prisoner cannot be seen on the CCTV then the observer should check on them in person.
On the hearing’s final day Mr Hughes told the jurors they had to “determine how and in what circumstances, when, and where Mr Perry came about his death”.
He said the jury should consider three main issues: firstly, the ACCT observation regime – that is, cell or accommodation checks – in place in the safer custody unit in October 2019; secondly, evidence of and compliance with ACCT observation checks between 11am and 11.50am on October 30; and finally the process of transferring Perry to secure psychiatric unit and its efficacy. He told the jurors to determine, with relation to these central issues, whether any act or omission on the part of the prison, former prison officers, and the two health boards on the balance of probabilities more than minimally, negligibly, or trivially caused or contributed to Perry’s death.
The jury recorded a conclusion of “misadventure to which a failure to undertake indicated observations, a delay to his transfer to a secure mental health unit, and failure to remove material as per procedure contributed”.
Dr Richard Self of the Princess of Wales hospital gave the medical cause of death as 1b airway obstruction due to hanging leading to 1a hypoxic brain injury.
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