Gareth, 41, was admitted to HMP Altcourse on 29th September 2016 and was found hanging on 1st October 2016, less than 48 hours later. The Inquest heard a plethora of failings by staff working at HMP Altcourse.

Upon arrival into custody, he was identified as suffering from opiate withdrawal. The jury heard evidence that Gareth also suffered from severe back pain. He made many individuals aware of the severity of his pain during the entire time he was in State custody. It was admitted by Geoamey that despite being aware of Gareth’s suffering, they did not make any enquiries about whether or not Gareth wanted to see a medical practitioner and admitted that these enquiries should have been made.

Gareth was admitted to Altcourse with a Prison Escort Record (PER) which highlighted a risk of suicide and self-harm. When Gareth was admitted to HMP Altcourse, he was prescribed methadone and placed on a detoxification programme due to presenting with withdrawal symptoms. The evidence confirmed that, whilst on such a programme a prisoner must be monitored closely and observed to see how they are reacting to the detoxification treatment. It was confirmed that these checks are vital and if not carried out, they can have dangerous and fatal consequences. The substance misuse policy, which was in place at the time, stipulated that a prisoner who is placed on a detoxification programme must be observed and checked twice a night for the first five nights they are in custody.

During the day and evening of 30th September 2016, Gareth continuously made requests to prison officers for medical assistance in relation to his back pain. The Court heard evidence from Gareth’s cellmate that Gareth was crawling on his knees due to the pain. He was informed that healthcare staff would attend the wing to see him. In the evening, the day staff gave a verbal handover to the night staff specifically informing them that Gareth had continuously rang his cell bell raising complaints of back pain and that a nurse should be attending to see him that night. During the night state, Gareth persistently rang his cell bell seeking medical assistance and enquiring about when he will be seen by a medical practitioner. Gareth informed the officer on night duty that if he does not receive any medical assistance regarding his back pain he will “cut up in the morning.”

This officer contacted the Duty Operations Manager (DOM) who is responsible for the prison during night state. The officer informed the DOM that Gareth was complaining of back pain and the DOM advised the officer to contact healthcare. The officer did not inform the DOM of Gareth’s remark of self-harm. The Officer contacted healthcare as advised but again failed to inform the nurse on duty of this comment. The jury heard evidence from both the DOM and the Nurse, that they would expect such information to be passed over to them. There was an admitted failing by the officer that this information should have been handed over on both occasions.

It was agreed that any threats of self-harm are serious and should trigger an ACCT being opened and the appropriate procedures to assess the prisoner’s risk carried out. The Officer did not open an ACCT despite this comment and made a “judgement call” not to open one. The nurse on night duty did not carry out the mandatory two nightly observations neither did she attend the wing to see Gareth in response to his complaints of back pain. It was conceded in evidence that the failure to carry out observations was a failing.

Gareth was found hanging at approximately 8:30am on 1st October 2016. He received emergency medical treatment but sadly the paramedics pronounced him dead at 9:16am.

After hearing this evidence, the jury returned the following conclusion;

We are sure that Mr G McCarroll did not put himself in this position in which he was found with the intention of ending his life. We believe that Mr G McCarroll put himself in this position as a cry for help or out of frustration which inadvertently proved fatal. Evidence given states that Mr G McCarroll did make a verbal statement to self-harm, which was recognised but not managed adequately according to the Assessment, Care in Custody and teamwork (ACCT) system.

The procedure states that if there has been any statement of self-harm an ACCT must be opened.

There was a failure to perform 2 night checks on Mr G McCarroll as a detoxing prisoner. We believe this was a contribution to the circumstances leading to the death of Mr G Mccarroll.

Mr Gareth Patrick McCarroll has died from an accidental death. We believe that there were two contributing factors: The failure to raise an Assessment, Care in Custody and Teamwork (ACCT), the failure to perform two night checks.”

The family of Gareth would like to say the following:

The inquest has brought to light many failings in the systems at Altcourse which we hope above all else will be rectified immediately to avoid any unnecessary repeats of this tragic and avoidable loss of life.

The subject of inadequate prison staffing levels and budget constraints has been widely and repeatedly criticised and publicised over the course of the past 12 months, unfortunately to no avail for Gareth and ultimately, we believe it cost Gareth his life, however for us, there is little solace taken from apportioning blame. We can eventually come to terms with our loss and would like to extend our deepest and most sincere thanks to Broudie Jackson Canter & Garden Court Chambers for their assistance and counsel during this difficult time. 

Their belief in the cause, their willingness and persistence in making the case has helped us to uncover the truth and fully understand the circumstances surrounding Gareth’s death, for which we shall be eternally grateful.”

Jenny Fraser, Solicitor representing the family, said:

This is a very sad and tragic death of yet another prisoner. It is crucial that lessons are learnt by all to prevent any future deaths from occurring. It is vitally important that all prisoners are receiving the correct medical treatment, appropriate monitoring and safeguards are put in place to protect current and future prisoners.”

The family is represented by INQUEST Lawyers Group members Jenny Fraser and Leanne Devine from Broudie Jackson Canter Solicitors and Ifeanyi Odogwu from Garden Court Chambers.