WE WILL SUE PRISON OVER OUR SON’S DEATH
FAMILY VOW TO TAKE ACTION AGAINST PRISON AFTER INQUEST FINDS FIVE FAILINGS LED TO DEATH OF PRISONER
AKNOWLE man died in prison after a series of failings by mental health services which contributed to his death, an inquest jury has found.
There were five separate failings by mental health and the prison authorities that, on the balance of probabilities, contributed to the death of Kevin Crehan.
Now his family said they will take legal action against HMP Bristol and that they are ‘appalled’ the prison authorities are ‘failing to learn from their mistakes’ about the way they treat prisoners.
An eight-day inquest at Avon Coroner’s Court heard Crehan had a history of suicidal thoughts, overdose attempts and deteriorating mental health.
The jury was told how he overdosed at HMP Bristol in Horfield on December 23, 2016 and was rushed to Southmead Hospital. He was discharged from hospital on Boxing Day. But that night he overdosed on diazepam and morphine.
A post-mortem toxicology report found he had a cocktail of five prescription or illicit drugs in his bloodstream, but it was the combination of morphine and diazepam that killed him.
In a narrative verdict, a jury of 11 men and women found several failings in how Crehan’s case was handled, but that they did not contribute to his eventual death.
But there were five specific failings that meant that Crehan was returned to C wing at Horfield on Boxing Day without adequate health screening, without adequate communication from healthcare staff to prison guards and was able to move freely around the wing, obtain some illicit prescription drugs and overdose that night.
At the inquest Bristol Community Health, Avon and Wiltshire Mental Health Partnership and the Prisons Service were all represented by lawyers, arguing the way the authorities dealt with the 35-year-old in the last few days of his life did not contribute to his death, but the jury found against them.
The jury’s narrative verdict explained there were ‘failings or omissions of care’ which contributed to his death.
The first was the failure – when Crehan suffered an overdose in prison on December 23 – to open an urgent medical referral, incident report or an ‘ACCT’. This is prison shorthand for a process called ‘ Assessment, Care in Custody and Teamwork’, which would have alerted medical staff, mental health staff and prison authorities to Crehan’s vulnerable state and mental health.
The second was the failure to find and process a note written by Crehan before that December 23 overdose. He wrongly dated it 21/4/12, but it is believed he wrote it on December 21, which requested mental health help.
The third was the failure, when Crehan was brought back to prison from hospital on Boxing Day, to provide a ‘full healthcare screening’, which would have flagged up his deteriorating mental health.
Earlier, the jury heard that, had a screening been done and it was spotted Crehan’s mental health required an urgent referral, there was a member of the mental health staff team on duty, even though it was Boxing Day, and Crehan would have been seen.
The fourth and fifth findings of failure by the jury were around a failure of communication between all those involved in dealing with Crehan in the period following his first overdose on December 23.
There was a failure to provide all the relevant physical and mental health information to the prison staff on the night shift, and there was ‘inadequate communications and information sharing’ between the authorities and all the various agencies within the prison.
The jury found that it was ‘not possible’ to know whether Crehan intended to take his own life by taking the drugs he did on Boxing Day night.
Crehan was nearing the end of the custodial part of a one-year sentence he was given in the summer of 2016 and was just a few weeks from being released from prison on licence.
The 35-year-old had been jailed for a racially aggravated public order offence when he and a group of friends protested outside a mosque in Totterdown, Bristol, in the January of 2016.
Crehan placed bacon on the mosque door and the group shouted abuse at elderly people entering and leaving the mosque.
The judge said he was jailing Crehan because the offence was the latest in a long list of previous convictions, mainly for football-related violence.
A statement released by the family of Kevin Crehan spoke of how they were ‘appalled’ at what had happened to him, and the way he was treated by prison authorities.
“This inquest has highlighted a number of failings at HMP Bristol relating to the management, care and wellbeing of prisoners in their custody,” the family statement said.
“We strongly believe that these systemic failings contributed to Kevin’s death...
“We are appalled that HMP Bristol do not seem be learning from their mistakes and vulnerable prisoners continue to die in their custody as identified by HM Inspectorate for Prisons in their report in March 2017.”
The inquest had earlier heard that Bristol Prison was awash with drugs at the time Crehan was first transferred there on November 30, 2016, because a member of staff inside the prison had been smuggling in drugs and phones.
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We are appalled that HMP Bristol do not seem to be learning from their mistakes and vulnerable prisoners continue to die in their custody
Family statement