Man died in prison after police wrongly took him from psychiatric unit, inquest finds
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Version 0 of 1. An inmate took his own life by throwing himself head first from his bed days after being wrongly recalled to prison from a psychiatric unit, a jury has found. The verdict at the inquest into the death of Mark Groombridge at Dovegate prison criticised the probation services, the NHS and the prison for the way they handled a man who had serious mental health problems and a history of self-harm. Groombridge was being held voluntarily in a secure ward in hospital after taking an overdose while out on licence. He was wrongly removed from the ward by the probation service and returned to prison, where he died. The court found: “On the balance of probabilities it is felt that the execution of the recall process contributed to the death of Mark Groombridge.” Groombridge, 52, from Uttoxeter, died at Dovegate prison, which is operated by Serco, in Staffordshire on 27 December 2013. The inquest, at Stafford coroner’s court, heard that he had been released on licence from a 12-year sentence imposed for attempted murder in January 2013. In December 2013, three weeks before his death, Groombridge took a life-threatening drug overdose and lapsed into a coma. He recovered and was admitted as a voluntary patient to an acute admission secure ward at St George’s hospital in Stafford. The hospital made it clear to Groombridge that should he attempt to leave without staff approval, he would be sectioned under the Mental Heath Act. Adele Montgomery, a probation officer who dealt with Groombridge’s case, told the jury she had been advised to provide a recall notice, which would see him returned to prison if he left the ward, to be left on Groombridge’s file. But Marlon Haytread, from the National Offender Management Service, told the inquest the paperwork he received marked Groombridge’s case as an emergency, and the police were informed. On 12 December, a senior psychiatrist at St George’s decided a full assessment of Groombridge’s mental state was required because he was showing signs of severe depression and psychosis. But on 14 December, armed police removed Groombridge from hospital and returned him to prison before the assessment could take place. A hospital investigation found that, on the day Groombridge was taken from St George’s, junior staff on duty failed to get a medical assessment of his fitness to be removed. They tried to contact the on-call consultant psychiatrist, but found he was on sick leave. Shropshire and South Staffordshire Hospital Trust has apologised to Groombridge’s family for the failings on the day. The hospital has since conducted a review of the practice and says it has put in place new measures that include “training staff in how to respond in the event of police wishing to remove or arrest a patient, a duty to ensure patients are medically fit to be discharged and a system put in place for covering unexpected absences of on-call consultant psychiatrists”. The jury, who delivered their finding on Thursday, heard that Groombridge had inflicted deep lacerations to his hand while in Dovegate in the week before he died, and told staff he wanted to die. He was placed on suicide watch, but the officer charged with observing him had no training or experience of such supervision. Groombridge was not seen by a psychiatrist at Dovegate. He died after throwing himself from his bed head first, fracturing his skull. Figures obtained from the Ministry of Justice, the Department of Health and other sources, show 10% of men and 30% of women in prison have had a previous psychiatric admission before they entered prison. In a review of mental health in prisons in 2013, Nick Hardwick, then chief inspector of prisons, said prison had become, “to far too large an extent, the default setting for those suffering from a wide range of mental and emotional disorders”. The jury concluded that prison was an environment less conducive to Groombridge’s wellbeing and that he was less able to undertake psychiatric assessment and continue the treatment he had received at St George’s. Speaking after the verdict, Ruth Bundy, who represented the family, said when Groombridge’s wife, Jackie, realised he was ill, she told the relevant authorities and did all she could to ensure he got help. “While the NHS trust has apologised from the beginning for their failings when armed police attended the psychiatric unit, this is in stark contrast to the local probation unit, who have provided contradictory accounts in self-justification.” She said the last straw was the failure of “constant supervision” at Dovegate prison. “There was an untrained officer, separated from Mark by a locked door, viewing him through a hatch, unable to prevent his final act,” she said. Deborah Coles, co-director of the charity Inquest, said it was a scandal that Groombridge, who clearly had serious mental health problems, was put in prison in the first place. “If someone with physical health problems was dragged to prison halfway through his treatment there would be an outcry; why should it be different for someone having a severe mental health crisis? “The findings of his inquest should send a strong message to the authorities that prisons are no place for people with mental health problems,” she said. South Staffordshire coroner Andrew Haigh said he would submit a report to the secretary of state for justice about the recall process when a person is in hospital, and seek confirmation that staff understood the process so there could not be further misunderstandings. |