Jury at Inquest into the death of Nathan Vaughan Jones delivers damning verdict
15 Sep 2016
Nathan Vaughan Jones was found hanging in his cell at HMP Lewes on 27th July 2012. An inquest into his death began on 29th June at the Eastbourne Town Hall On 3rd July 2015 the jury returned a narrative verdict in which they said:
At 20.34 on 27th July 2012 the deceased was found hanging by a shoelace from the top bunk-bed in a single cell no 215 at HMP Lewes. He had been locked up for at least three hours before he was found. He left suicide notes. The deceased who was a first time offender suffered with chronic fatigue and depression and evidence has shown he had difficulty coming to terms with living with his guilt and remorse over his crime. All of which were contributing factors in his death.
We find the failure to undertake an initial mental health interview after sentencing contributed to a lack of ongoing monitoring which could have led to early intervention.
Whilst receiving support from the Chaplaincy team opportunities to open an ACCT Document were missed. This omission was a contributing factor in the deceased’s death.
Lack of response to the deceased’s letter to the governor was a contribution in the decline of the deceased’s mental state.
Insufficient evidence in prison records showed that prison staff were not meeting their duty of care to the deceased’s right to life. This lack of communication between different departments was detrimental to the deceased.
Mr Vaughan Jones had been serving a sentence at HMP Lewes when he died. During the inquest the jury heard evidence that he had suffered from a history of depression as well as a number of physical health conditions such as chronic fatigue syndrome (ME). Evidence was also heard that following his return to HMP Lewes after a period on bail Mr Vaughan Jones ceased to be under the care of the Mental Health Inreach Team as he had been previously. The jury was told of a letter Mr Vaughan Jones had written to the governor of HMP Lewes a month before his death expressing his concerns about bullying and his fears that prisoners and prison officers were seeking to gather information about him and his criminal case. That letter had gone unanswered. No action was taken following an incident in which another prisoner had allegedly threatened to “cut” Mr Vaughan Jones.
The inquest also heard that in the weeks leading up to his death Mr Vaughan Jones’ physical health deteriorated and he ceased leaving his cell. He saw a counsellor days before he died and she noted that he was ”incredibly anxious” and ”visibly shaking”. She said he reported bullying and was ”physically scared” to leave his cell. The counsellor had asked him about medication and a razor blade which were in his possession and asked him whether he was planning to do anything ‘silly’. No record was made of these issues and an ACCT (the prison suicide monitoring procedure) was not opened.
At the conclusion of the inquest the Coroner, HM Senior Coroner Alan Craze said of the deceased ‘‘He was a kind, respectful, intelligent and honest young man who, in the words of many people, shouldn’t have been in prison. I cannot begin to understand how difficult things must have been for him. For his relatives, this is a devastating and life-changing tragedy.”
Nathan’s mother Stephanie Ross says:
“It has been three years since Nathan’s death and we have had a long fight to try and get answers as to why he died in prison. We are grateful to the Jury for highlighting the steps that the prison could and should have taken to protect Nathan and I believe firmly that had they done so Nathan would be with us today. This process has helped deliver some of the answers that we were seeking but there are matters we still do not believe have been thoroughly investigated and we will now fight to ensure that happens. Nathan was a wonderful son and myself and all who loved him miss him hugely”.