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Jury finds a series of failings at Bristol prison caused the death of father-to-be


Callum Smith repeatedly self-harmed and threatened to kill himself but was not put on a suicide prevention plan. A report by law firm Irwin Mitchell.

The family of a father-to-be found hanged in his cell at HMP Bristol is calling for meaningful change after an inquest found a series of failings leading up to his death in March 2016.

Despite Callum repeatedly self- harming and threatening to kill himself while at the prison, he was not placed on an self harm and suicide prevention plan (known as an ‘ACCT’).

Callum Smith, 27, from Cheltenham, had recently begun suffering from paranoia and delusions when he was remanded into custody at HMP Bristol after allegedly making threats to commit criminal damage during a mental breakdown. During his detention by Gloucestershire Constabulary and then at HMP Bristol he repeatedly self-harmed and threatened to kill himself. He was discovered hanged in his cell on March 2, 2016, six days after being remanded, and was pronounced dead at the scene.

His distraught family instructed expert civil liberties lawyers at Irwin Mitchell to investigate the events leading up to his death and to represent them at an inquest.

The eight-day inquest concluded today in Avon Coroner’s Court in Bristol, with the jury concluding that Callum’s death was caused by:

  • Inadequate attention to the concerns of Callum’s family, his own requests for help and for communication with his family, the level of his anxiety, and acts of self harm whilst in police and prison custody.
  • Failures to record key events on the Person Escort Record [which accompanied Callum from police custody to prison] and to include health and mental health records on transfer to prison.
  • Inadequate communication between those involved in Callum’s care.
  • An inadequate mental health assessment [in prison on February 29, 2016] and failure to carry out a timely full mental health assessment and to ensure that a proper referral took place with handover.
  • Repeated failures to open an ACCT due to lack of training, inadequate training and staff understanding, failure to take responsibility for the opening of an ACCT and failures to recognise that self harm extended to Callum banging his head against a wall or a door.
  • Inadequate integration between, and access to, IT systems which led to key information being missed.
  • Failure to support Callum by not allowing a follow up assessment to take place.

The jury further concluded that Callum was suffering from extreme anxiety and distress when he committed suicide.

The jury was asked to consider a number of issues including the adequacy of information provided to the prison by Gloucestershire Constabulary about Callum’s risk of self-harm and the implementation and adequacy of risk assessments and suicide prevention procedures at the prison.

Senior coroner for Avon, Maria Voisin, said that she would be sending a ‘Preventing Future Deaths’ report to the Avon and Wiltshire Mental Health Partnership NHS Trust, which provides mental health services at the prison, and Bristol Community Health, which provides detoxification services. The report will set out her concerns that further deaths could occur due to the quality of training for healthcare staff regarding the ACCT regime.

“I called the police because Callum was going through a crisis and we couldn’t get help anywhere else.”

Gus Silverman, a civil liberties lawyer at Irwin Mitchell representing Callum’s family, said:

“From the point of his arrest until the day of his death Callum was obviously mentally unwell and profoundly vulnerable. It is truly shocking that someone this ill was in prison in the first place.

“Callum repeatedly told police officers, prison officers and healthcare staff that he would kill himself. It is tragedy that no-one listened to him and took appropriate and obvious steps to keep him safe.

“Witnesses at Callum’s inquest gave evidence about lack of training and understaffing. It has been said many times that the prison service is in crisis. However, there is no sign of the political will needed to make urgent improvements and to provide the necessary resources to ensure that more families are not left grieving the loss of their loved ones in prison.

“A familiar mantra of ‘learning lessons’ is often repeated after deaths in our prisons. However, this is empty rhetoric so long as the prison service remains in crisis and we persist in sending seriously mental ill people to prison.”

Callum’s partner, Libby Smith, was pregnant with the couple’s second child when Callum died. She said:

“I didn’t want Callum to be arrested or for him to got to prison. I called the police because Callum was going through a crisis and we couldn’t get help anywhere else.

“When he was first remanded the police told us that he would be on a psychiatric wing and would get the help that he needed. This didn’t happen. It has been very difficult to sit in court and hear witness after witness say that Callum was self-harming and threatening to kill himself but nothing was done. I really think people need to open their eyes to how we treat prisoners in this country.

“After Callum was arrested there were so many opportunities for someone to step in and make sure that he was kept safe. The fact that no one did this means that my two children will now grow up without a father. Our daughter was the apple of Callum’s eye and I know that he would have been a wonderful father to our son who he never go to meet. I miss Callum every day and wish that he was still with us.”

Callum’s mother, Sandra Smith said:

“Callum was the eldest of my four children and was very much loved by his family. He struggled with drug addiction throughout his life but he never stopped trying to get better.

“When he was arrested I thought that he would be looked after and would get the help he needed. You always assume that people know how to do their jobs but it has been a terrible shock to hear that so many people failed in so many ways to respond appropriately to the very obvious risk that Callum posed to himself.

“I can only hope that some good will come from Callum’s death and that changes will be made to make sure that other families don’t have to suffer like we have. Prisoners are people too and they deserve to be treated with professionalism and care. It is a tragedy for our family this didn’t happen in Callum’s case.”

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