HMP Woodhill death: Prison 'failed to take appropriate steps'
The death of a prisoner could and should have been avoided, an inquest jury has found.
Thomas Morris, 31, was found hanged in his cell at HMP Woodhill, near Milton Keynes, in June 2016.
The jury at Milton Keynes Coroners' Court recorded a verdict of suicide, after hearing warnings about his mental health were ignored.
They concluded the prison authorities did not take appropriate steps to prevent the loss of Mr Morris' life.
The inquest heard from fellow inmates that Mr Morris had sought mental health care before his death.
The jury found the prison authorities had failed to properly assess his mental health, failed to carry out appropriate ACCT (assessment, care in custody and teamwork) reviews and prison staff failed to share relevant information on his condition and these caused or contributed to his death.
They also found Mr Morris should not have been transferred to a single cell in the days before his death and there had been a failure to properly implement previous findings, which also caused or contributed to his death.
Following the jury's findings, the Milton Keynes senior coroner said this sort of situation cannot be allowed to continue and should be addressed by the government.
Thomas Osborne said: "The use of ACCTs [designed to alert the authorities to prisoners with suicidal or other mental health situations] had to be kept under review as due to a risk-averse nature too many were being actioned.
"We must learn from our mistakes and whenever systems are exposed they must be changed."