Floyd died on 14th June 2021 after not leaving his cell for four days, and not eating multiple evening meals. He was found by prison staff collapsed in his chair on 29th May 2021. After being conveyed by ambulance to Birmingham City Hospital, he was discovered to have bacterial endocarditis which had led to septic shock and multi-organ failure. The bacterial endocarditis likely developed while he was in prison, in the weeks or months before he collapsed.

Floyd’s inquest was held at Birmingham & Solihull Coroner’s Court between 12th – 22nd December 2022 before Assistant Coroner Ian Dreelan and a jury.

The jury found that the prison staff failed to take sufficient steps to safeguard Floyd, including insufficient record keeping, handovers and escalation. Prison staff were found to have had insufficient training in, and understanding of, the National Offender Management Service (NOMS), Adults Safeguarding in Prison policy, PSI 16/2015, to allow them to undertake their role in compliance with that policy. In particular, there was a serious failure to make a referral to healthcare based on Floyd’s overall pattern of behaviour and presentation, which amounted to neglect.

The court heard from an expert cardiologist that Floyd likely went into septic shock and multi-organ failure during the night of 28th May 2021. Had he been conveyed to hospital before this time, he probably would have survived.

The Ministry of Justice and HMP Birmingham accepted that there was no system in place for staff to identify patterns of behaviour over multiple shifts, and that staff were not recording single incidents of prisoners not leaving their cells or refusing meals. Consequently, at the end of the first week of evidence, on 16th December 2022, the Governor Paul Newton issued a Governor’s Order mandating that prison staff must record every time that a prisoner fails to access the regime e.g., by refusing to leave their cell or have an evening meal.

Floyd had suffered with mental health problems for over 20 years and had a diagnosis of paranoid schizophrenia. He had been living in Midlands Heart Housing for 30 years where he had a designated housing officer who was aware of his mental health history and that he was receiving treatment from the community mental health team.

In March 2021, Floyd was reported by the housing association to police for breaching an anti-social behaviour injunction. He was arrested and held in police custody for three days before being transferred to Birmingham prison on 12th April 2021. Unfortunately, during his medical screening, staff did not identify Floyd’s mental health condition or treatment in the community, and so he was not seen by the prison mental health team within 48 hours of arrival, as he should have been.

Healthcare staff did note that Floyd had a pacemaker fitted, and that more information was needed, but this was never followed up.

Following his arrest, Floyd’s family raised their concerns about his mental health directly with the prison. They were assured that he was okay. Floyd’s family also contacted the community mental health team but were told that they could not give any further information due to confidentiality.

The Coroner issued a Prevention of Future Deaths (PFD) report in respect of the failure of prison staff to comply with PSI 16/2015.

Commenting on the inquest conclusion, the family’s solicitor Lucie Boase of Broudie Jackson Canter said:

“Floyd’s family showed great courage in attending court each day of the two-week hearing. It was immensely difficult listening to evidence about the deterioration in Floyd’s health during his time in prison and the failure by prison staff to respond to this adequately.

Given the evidence which was heard, the jury’s finding that Floyd’s death was contributed to by neglect is a vindication. While nothing will be able to bring Floyd back, it is hoped that lessons learned during the course of the Coroner’s rigorous investigation into his death will help to prevent future deaths.”

Floyd’s family said: “We are relieved to have the answers we were looking for in relation to Floyd’s death. We are thankful for the jury’s time and engagement throughout the inquest, and in coming to their conclusions, and we hope that lessons are learned by the prison to make sure another family do not have to go through the pain we have over the past 19 months. We loved Floyd immensely and we miss him every day, and we will cherish our memories together.”

Floyd’s family were represented by Lucie Boase and Nicola Miller of Broudie Jackson Canter and Matthew Turner of Doughty Street Chambers. The family were supported by INQUEST caseworker Jodie Anderson.

Get in touch with Lucie Boase.