Suicide verdict in jail cell death case
THE death of an inmate who was found dead in his cell two days after being admitted to prison was suicide, an inquest has heard.
Dean Gary George, aged 40, was found hanged in his cell at Swansea Prison on April 10, 2016.
Described by his mother, Lynette George, as being a “lovable rogue”, Mr George was sent to prison on this occasion for theft-related offences.
Mrs George described how she struggled to come to terms with Dean’s death and felt the system had failed him.
Mr George, originally from the Cwmavon area, had been in and out of prison and had a history of anxiety, previous selfharm and suicide attempts. He was also said to be a “serious heroin user” and had issues with alcohol.
The acting senior coroner for Swansea and Neath Port Talbot, Colin Phillips, gave the jury facts from the evidence on which they could base a conclusion of suicide.
He said: “Dean experienced suicidal thoughts and said he had nothing to live for.
“He mentioned the hanging attempt shortly before attending custody.
“He withdrew from social contact and was described as being very down by his cellmate.
“He waited for his cellmate to leave before attempting the suspension.”
Previously, Mr George’s cellmate and friend, Phillip Holborn, said in read evidence that Mr George seemed “very ill” leading up to his death and “was not himself at all”, which he thought was likely to have been related to drug withdrawal.
Mr George had been placed on an ACCT (assessment, care in custody and teamwork), after he disclosed to a prison officer he had tried to take his own life three weeks before attending prison.
Despite this, some members of staff reported having “no concerns” about Mr George’s mental state, and did not know why he had been placed on the ACCT.
As part of the system, an assessment on at-risk individuals should be carried out in the first 24 hours a prisoner is placed on one, but, contrary to this, it was not carried out.
The inquest heard from Michael Pulford, a clinical reviewer at the Prisons and Probation Ombudsman, who said that at the time of Mr George’s death, Welsh prisons, including Swansea Prison, generally had a “cold turkey” approach to inmates with serious addictions.
He said they offered “symptomatic relief” rather than drug substitutions and that this was a government decision and not up to individual prisons.
He explained how this method could leave inmates suffering brutal withdrawal symptoms and was a suicide “risk factor”.
The inquest jury concluded that Mr George died by hanging, and found that the following issues contributed to his death: ■ “Withdrawing for opiates against his will”; ■ “Inadequate risk assessment”;
■ Lack of communication between medical and prison staff; ■ ACCT training that was “inadequate with some officers being untrained”; and ■ The system in place for managing opiate withdrawal which “was not equitable to what Dean would have access to in the community”.
Lynette (Denise) and Gary George, Dean’s parents, said: “After four years of waiting for this inquest, we feel that justice has been done for Dean. The jury have confirmed what we knew all along, that Dean was failed when he needed help. We hope other families don’t have to go through what we have.”
The coroner indicated that he intended to write a Report to Prevent Future Deaths arising from the lack of a permanent system for opiate substitution therapy in HMP Swansea equivalent to that which is available in the community.
This will be issued to the Welsh Ministers for the attention of Vaughan Gething, Minister for Health and Social Services, and to Swansea Bay University Health Board for the attention of Tracy Myhill, chief executive.
The coroner will be writing to the Governor of HMP Swansea regarding concerns over the adequacy of the CCTV system, which during the inquest was acknowledged as “not being fit for purpose”. For reasons that remain unclear, officers’ evidence about the two hours before Dean’s death – given in statements to the police, Prison and Probation Ombudsman and under oath to the inquest jury – directly conflicted with CCTV and cell bell records.
Welsh Government, Ministry of Justice and Swansea Bay University Health Board have been approached for comment.
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