Inquest into the death of Oliver ‘Olly’ Nicholas John Owen Jones (a.k.a. Oliver Huxter)

BEFORE HER MAJESTY’S ACTING SENIOR CORONER, MR COLIN PHILLIPS

JURY CONCLUDE THAT ACCT PROCEDURE WAS INADEQUATE

 Monday 3 February 2020 to Friday 7 February 2020

Oliver Jones, known to his family as Olly, tragically died on 11th March 2014 in HMP Swansea after being discovered suspended by a ligature in his cell.

Olly had entered HMP Swansea on 19th February 2014 with a 166 day sentence. On his first night he told the nurse that he wanted to ‘kill himself by any means necessary’ and was tearful during this interview. Olly had a history of depression, previous self-harm and suicide attempts. He was then placed on an ACCT (Assessment, Care in Custody and Teamwork) which is the procedure used for care planning for prisoners identified as ‘at risk of suicide or self-harm’. He remained on this for nine days, over which time he underwent four ACCT case reviews. The Prison and Probation Ombudsman acknowledged, following Olly’s sad death, that these reviews were not consistent in terms of staff, and were not sufficiently multi-disciplinary. Olly was also referred to Lighthouse, the mental health care team within the prison, but was not scheduled for an appointment for almost four weeks from the time that he was referred. Sadly, the date of his appointment was the following Monday after he died.

The ACCT was closed on 28th February 2014. During the inquest, it was not clear through evidence that other staff knew that his mental health appointment was still outstanding. This revealed issues with the Care Map, which forms part of the ACCT, in terms of communicating information to other staff about which actions had been completed. It was also not clear if triggers for decline in Olly’s mental health were clearly communicated between staff members.

On 11 March 2014 Olly asked to speak to the Chaplin, as he was concerned over when he would be seeing his family. He was later discovered by his cell mate, who was returning from hospital, suspended from a ligature in their shared cell. Staff rushed to his aid, but sadly he was later pronounced dead by paramedics.

At the conclusion of the inquest the jury returned a narrative, finding:

• The ACCT reviews were completed with inadequate attendance by multidisciplinary teams from the third case review through to the post closure review
• The Care Map was incomplete in that outstanding issues were not updated to the Care Map
• Had the Care Map been appropriately updated the ACCT could, and should, not have been closed whilst the outstanding appointment with Lighthouse had not been completed
• The frequency of formal ACCT training was found to be insufficient
• Evidence of communication failures were suggested by the lack of multidisciplinary attendance, from the third case review through to closure
• There was sufficient evidence that the prisoner had significant mental health issues at the time of his initial custody

There have been multiple issues with the Inquest process, which include holding the inquest six years after Olly’s death, preservation of evidence, and disclosure of information to the family. The family were still receiving hundreds of pages of disclosure two weeks before the inquest, with other documents coming in on the Friday before the inquest began, after asking for documents for almost six years. Parts of the ACCT document have been lost, so it is impossible to confirm exactly what staff knew at the time.

The Court has had difficulties with technology and their online portal. Sadly, due to this the family have suffered a considerable amount of distress and have struggled with the grieving process due to the delays in this final Inquest being heard.

The family have suffered a considerable amount of distress and have struggled with the grieving process due to the delays in this final Inquest being heard.

Jessica Mullins, Olly’s partner said:

I cannot begin to put into words what a difficult and horrendous process this has been for me and my daughter. Olly died in 2014, and it is only now, almost six years later, that we are getting some answers. There is no excuse for the delay Six years is too long to wait. I have been under constant stress this whole time, and it has delayed the entire grieving process for me. Our daughter has grown up in this time, and she has started to ask questions about where her dad is. It’s hard to know what to say, and what I could and couldn’t say while these proceedings were still ongoing. There were so many unknowns all these years.

I have felt so incredibly isolated throughout this process. Losing someone you love when they are also in custody it is so much different than other types of bereavement. It is a special type of trauma, and there is no support for it, and no wider understanding of the issues. Other people do not understand what you are going through, and I did not feel, as it was still ongoing, that I could even talk about it. It’s caused untold stress and anxiety on me and my family.

The massive delay in holding the inquest has also meant that evidence has been lost. CCTV has been lost, and we can never get clarity about why now, because it has been too long. We are missing parts of the ACCT document, vital parts, which cannot now be recovered. Had this been dealt with years ago, perhaps this evidence would have been preserved. There has also been an unforgivable mistake on the part of the police in how they dealt with the notes left by Olly, which means they have now potentially been lost forever. I wanted those for my daughter, for her to know what happened when she is older, and to know how much her dad loved her. They have mishandled evidence, which the Acting Senior Coroner also has grave concerns about.  For the family, it was the last thing Olly left for us, and now we do not know if we will ever get them back.

More than anything though, I want to raise awareness about mental health issues. There is so much stigma around this topic. People struggle with mental health, and they are afraid to talk about it and reach out, but I want them to know that they are not alone. If I can reach out to just one person, to let them know that they are not alone if they are going through what I have gone through, then this public statement is worth it. I also hope I can reach just one person who is going through a mental health crisis, to let them know that there are people who love them, and to please reach out and get help.

After all this time, I can finally start to come to terms with what has happened. But it is not over, not for a long time. My daughter wants to know where her father is, and why she can’t go and visit him in the stars. The loss of her dad is never going to go away. I just wish that we had not had the added stress and trauma of this delayed inquest on top of our grieving.

I am so glad that the jury have recognised the failings on behalf of the prison to keep Olly safe. I finally feel like there has been recognition of what really happened.

Jenny Fraser and Charlotte Halsted of Broudie Jackson Canter Solicitors said:

This is such a tragic case of an unnecessary loss of life in prison, and the effect that it can have on those left behind. Those who are incarcerated are deprived of their liberty but this should not be a deprivation of human rights.  Prisoners should have access to at least the same level of healthcare, including mental healthcare, which is available in the community.  Prisoners are often particularly vulnerable to mental health issues and have an increased need for mental health services.  Adequate healthcare services should be available within our prisons and safeguards in place to ensure prisoners are safe. The funding cuts that have been made to prison services are simply not acceptable and are impacting on services available.

It is also clear that there should be a priority to increase funding to Coroners. At present the delays and inadequacies are simply unacceptable, especially as they directly affect grieving families. 

The inquest process is meant to investigate the circumstances of a death and to recommend change to prevent future deaths from occurring. The process has a fundamental role in our society. This process is totally broken when so much time has passed, and we urge a review of the provisions made to Coroners.