'Missed opportunities' in case of man who took his own life at HMP Liverpool

Yahoo

8 hours ago

Prison staff "missed opportunities" to help a suicidal man at HMP Liverpool in the weeks before he took his own life. Daniel Edwin Fielding, 38, was found hanged in his cell on the morning of January 19 last year.
The dad-of-one, who arrived at the prison on remand on October 13 2023, was known to suffer from mental health problems, and was on mood-stabilising medication. He had been placed on an emergency Assessment, Care in Custody and Teamwork (ACCT) twice due to incidents of self harm - once on December 13, and again on December 30 - but these were closed following further assessments.
At a five-day inquest in June, coroner Johanna Thompson said: "Danny had a history of problems with his mental health and some illicit drug use, and he had made attempts to end his life and to harm himself in the past.
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"He was sadly found in his cell on the morning of January 19 2024." A jury handed down a unanimous conclusion of suicide.
Following his death, an independent investigation was carried out by the Prisons and Probations Ombudsman. A report published on Friday, July 25, said Mr Fielding "had several risk factors including an extensive history of deliberate self harm and suicidal thoughts, mental illness diagnosis, personality disorder diagnosis, recent contact with psychiatric services, impulsiveness, relationship difficulties, and drug use."
It found there had been "missed opportunities" in dealing with the ACCT plans - both of which were put in place after Mr Fielding's mother left voicemails reporting her son had self-harmed.
A PPO spokesman said: "We have some concerns about the management of these ACCTs. Given Mr Fielding was regularly seen by a substance misuse worker, it would have been good practice to invite him to ACCT reviews.
"Despite Mr Fielding disclosing he was in debt during his first ACCT assessment, staff never subsequently discussed this with him or offered him support.
"The first ACCT opened had no care plan to identify ways to support Mr Fielding and lessen his risk to himself. When staff closed the first ACCT, no healthcare staff were present, nor did they provide any input. Given Mr Fielding's mental health diagnosis and prescription... this was a missed opportunity to holistically assess his risk.
"The Head of Healthcare told us she would expect staff to provide a written contribution if they could not attend a review. However, both prison and healthcare staff told us that this did not occur in practice.
"Staff closed his second ACCT after one day. Neither of the members of staff present had any previous knowledge of Mr Fielding or his significant risk history. Given this lack of knowledge, we consider this was premature, particularly as Mr Fielding said that the festive period was a trigger for him, and it was New Year's Eve."
They said prison staff had "placed too much emphasis on what Mr Fielding said, rather than objectively considering his known risk factors". Additionally, no attempts had been made to contact Mr Fielding's mum, Margaret Farley.
However, the ombudsman added: "We have not found anything to suggest that staff should have considered he was at increased or imminent risk of suicide when he died, or foreseen his actions."
Ms Farley told the inquest that she had called HMP Liverpool several times to express her concerns, and had left several voicemail messages on the safer custody answerphone.
The PPO said: "Staff responded to two of these calls, on one occasion almost 24 hours after receiving the call. The prison could not identify calls that Mr Fielding's mother said she made on 17 October, 7 December, or 9 January.
"When asked how members of the public would raise urgent concerns about a prisoner (as it could be considered these were), staff said that they should leave a message on the answerphone. We do not consider that this is appropriate where there are concerns about an imminent risk to a prisoner. The public should be able to raise these directly with a member of staff to act on immediately."
A separate "action plan" report said a full debt reduction strategy has since been developed by HMP Liverpool, aimed at understanding, preventing and responding to prisoner debt within the prison. The inquest had heard Mr Fielding had disclosed being in debt for vapes.
The plan also recommended: "The Governor should ensure that welfare checks are clearly defined in Liverpool's Safer Strategy, that staff complete welfare checks in line with this strategy and that there is a robust quality assurance process in place to ensure these checks are done correctly."
This followed findings that a prison officer did not complete an adequate welfare check on Mr Fielding on the morning of his death, as when she looked into his cell at 7.55am, "he had already hanged himself at this time, which she failed to notice".
The PPO said: "HMP Liverpool will review and update the current safety strategy to ensure that welfare checks are clearly defined. Staff will be reminded of the process for completing welfare checks when the revised strategy is published. Welfare checks are recorded daily and signed for in each wing's roll book."