Inquest jury highlights failures at HMP Elmley after death of Levi Smith

22 Feb 2017

At the end of a 14 day inquest, attended throughout by the deceased’s family, a jury has returned a detailed narrative conclusion, confirming that the failure of a Governor and his staff to segregate a vulnerable prisoner under Rule 45 of the Prison Rules possibly contributed to his death. The jury also identified a raft of other failures and short-comings of the prison but were not required by the Assistant Coroner to determine whether these also contributed to the death.

Levi Smith, aged 41, a member of a Kent based traveller family, died in his cell in HMP Elmley on the morning of 12 November 2014, having suspended himself with a ligature attached to the door frame. The jury concluded that the death was ‘accidental’ in that Levi’s deliberate act was a “cry for help” which resulted in an unintended outcome. An admitted failure by the night Operational Support Grade staff member (OSG) to conduct a required hourly check shortly before 05.30 am coincided with what appeared to be Levi’s last movements. The jury concluded that Levi died between 05.35 am and 05.45 am but were not asked to consider whether the missed check contributed to the death.

At the time of his death Levi had only four weeks of his sentence to serve before his release. From 22nd October 2014, after being moved to a different house block within the prison, Levi became very concerned about death threats from members of a rival traveller family housed with him. His genuine fear manifested itself in a series of panic attacks, some of which resulted in outside hospital treatment.

Over the next two and a half weeks Levi made numerous attempts to draw the prison’s attention to the risk he faced. He also began to commit a number of what were described in evidence as “trivial” offences to engineer his move to the segregation unit out of harm’s way.

Both national prison policies and local policies in force at HMP Elmley recognised that the behaviour displayed by Levi was characteristic of someone at risk of harm from other prisoners. Despite this, at no stage did the prison implement its own Violence Reduction Strategy which would have enabled an investigation into Levi’s reports of threats and a support plan to be put in place which ought to have included consideration of where Levi could be safely housed.

During the inquest the jury also heard evidence about Rule 45 (of the Prison Rules 1999) which allows the prison to remove prisoners from association if it is in the interests of good order or discipline or where it is in the prisoner’s “own interests”:

“Prisoners are segregated in their own interests when there are good and sufficient reasons for believing that the prisoner’s safety and well being cannot reasonably be assured by other means”.

At no stage was Rule 45 status granted to Levi Smith.

On the 11th November 2014 Levi was taken to the healthcare unit suffering from a severe anxiety attack and in very real distress, declaring that he would “string himself up” if he was relocated to the house block the next day. He informed officers he had been told by ‘a governor’ that he would. An ACCT (Action, Care, Communication and Teamwork) document was opened, noting the risk of suicide and making provision for hourly checks on Levi overnight. Officers attempted to assure Levi that he would not be returned to the house block before a review the following morning as part of the ACCT process. It would appear that these assurances were not sufficient to overcome Levi’s fear at the prospect of being returned to the house block. He was discovered suspended in his cell shortly after 6.45 am.

Levi Smith’s family was represented at the Inquest by Sean Horstead of Garden Court Chambers, Instructed by Beth Handley of Hickman and Rose Solicitors.


Levi’s oldest sister Racheal Smith said “We believe the prison failed Levi, they failed to look after him as they should have done. If they had looked after him and took my mum’s phone call more seriously than they did do, I believe my brother would still be alive today”

“We do miss him dearly and not a moment goes by that we don’t think of him. We miss him more than words can say”, Levi’s daughter Rachel said.

“Wherever I went, my son went with me, he was like my shadow, when Levi went a part of me went with him” (Levi’s father, Levi Smith (senior) said.

Solicitor for Levi Smith’s family, Beth Handley of Hickman and Rose Solicitors said:

“The jury concluded that the failure to place Levi on Rule 45 segregation possibly contributed to Levi taking his own life. By failing to guarantee his removal from association with those who had threatened him the prison needlessly created unbearable uncertainty about his safety. This was yet another unnecessary tragedy from which his family will struggle to recover.”

Deborah Coles, director of INQUEST said:

“What happened to Levi is another example of a prison system in crisis. The shocking fact that there has been 4 further self-inflicted deaths in the same prison speaks for itself and underlines the urgency for action and accountability. There is a disconnect between policies and practice where repeated inquest findings and recommendations are simply not followed.”



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