The criminal justice system “did too little to protect” a vulnerable inmate who electrocuted himself in prison, the Prisons Ombudsman has found.
Dean Saunders, 25, succumbed at HMP Chelmsford in Essex in January 2016.
He had been arrested the month before, after his father, Mark, was stabbed while trying to stop his son harming himself during a bout of paranoia.
Mark Saunders has called for the recommendations made by the ombudsman to be seen through.
On Friday, an inquest jury discovered Mr Saunders was “let down” by the prison and mental health services.
Nigel Newcomen, the Prisons and Probation Ombudsman told Mr Saunders was at “high risk of suicide” when he arrived at Chelmsford and identified “a number of weaknesses” in the prison’s handling of his case.
Mark Saunders, Dean’s father, said the family had questioned his placement in prison from the outset.
“Obviously our concerns were that he needed help and drug, we needed to find out “whats going on”, ” told Mr Saunders.
“There was no proper medical structure there[ in prison] to help him. We were lied to and mislead all the route through. We were devastated.”
The ombudsman said those involved in Dean Saunders’ care felt he should have been in a mental health facility rather than prison.
“I am also concerned that there appears to have been some disarray at Chelmsford about the process for transferring mentally ill prisoners to hospital, which meant that an opportunity to transfer Mr Saunders in December[ of 2015] was missed.
“Sadly, the criminal justice system did too little to protect this very vulnerable man.”
Speaking about research reports, Mark Saunders told: “I can’t walk away from this now without putting all the changes into place.”
Care UK, the healthcare provider at HMP Chelmsford, announced it was to quit its contract at the prison.
The company said it had attempted to resolve issues at Chelmsford Prison but the level of resources the prison planned to make available were “insufficient”.
The Dean Saunders case
15 December 2015: Dean is taken to Rochford Hospital after fears for his mental health are raised. He is later released into care of household 16 December: Dean’s father sinks himself onto a knife held a total of his son in order to prevent him harming himself 17 December: Assessed by G4S, Dean demonstrates signs of paranoia and speaks of killing himself 17 December: No medium secure mental health beds available anywhere in Essex for Dean 18 December: Seems in court accused of attempted assassination and is remanded in custody 21 December: Dean taken off constant watch and placed on half-hourly watch 22 December: Prison governor records he was aware of concerns that decisions about constant watch were being made on grounds of costs 28 December: Dean’s risk recorded as “high” 31 December: A medium procure unit bed becomes available and one doctor signs the forms for Dean to be sectioned 2 January 2016: Dean asked for the television( used to kill himself) to be removed from his room. It is removed 3 January: Television returned to the room 3 January: Dean asks to speak to the prison chaplain about “funeral plans” telling: “It is never too early.” He also asked for a solicitor to arrange a lethal injection to “speed things up” 4 January: Dean is found dead in his cell 5 January: Second psychiatrist – who was on leave – expected to sign paperwork for Dean to be sectioned into a procure unit