Four years following his death in 2018, an inquest into the death of Robert Lee Evans has concluded, with the Jury finding that serious failures by prison and healthcare staff at HMP Swansea probably contributed to his death.

Lee, as he was known to his friends and family, had been an inmate at the prison for just two days before his death.  

On the day of his death, Lee was seen on CCTV speaking to Prison Officers following his visit to the medical hatch. In the footage, Lee appeared to be distressed during this conversation. Prison Officers did not respond or react to Lee’s distress.

Soon after, he was seen on CCTV posting a letter. The letter, found after his death, stated that he believed his medication had been stopped. Lee was locked up in his cell at around 4:30pm the same day. He was found soon after midnight having taken his own life. No checks had been carried out on Lee between 4:30pm and shortly after midnight, when he was found.

What did the Jury find?

The Inquest Jury concluded that:

• Prison staff failed to adequately assess Lee’s risk of suicide and self-harm.
• Prison and healthcare staff failed to take appropriate steps to safeguard Lee whilst he was in prison custody by not opening an ACCT (Assessment, Care in Custody and Teamwork) and communicating information about his prescription to him.
• HMP Swansea did not have an adequate system of checks in place for Lee, despite the fact that he was undergoing alcohol detoxification and on the induction wing in the early days of his time in prison.
• The doctor responsible for Lee’s healthcare failed to properly review Lee’s medical notes and prescribe him with anti-depressant or detoxification medication.

Just nine days before Lee’s death, HM Inspectorate of Prisons published a highly critical report on HMP Swansea, condemning their ‘complacent and inexcusable’ approach to the safety and wellbeing of vulnerable prisoners, and their failure to respond effectively to the high levels of self-harm and suicide that had been found in new prisoners. It also reported that there had been four self-inflicted deaths in HMP Swansea within a week of inmates arriving. The subsequent report by the Prisons Inspectorate, issued in 2020, found that there had been two further self-inflicted deaths since the last inspection.

Assistant Coroner for Swansea, Kirsten Heaven, issued a prevention of further deaths report as she was concerned from the evidence, she heard that there remained deficiencies in the systems at HMP Swansea which meant that future deaths were possible.

Lessons can be learnt now that the Inquest has concluded.

Lee’s family were represented by David Pearson, a Solicitor in Broudie Jackson Canter’s Inquests and Inquiries team and Shanthi Sivakumaran of Doughty Street Chambers.  

Speaking on the conclusion of the Inquest, David Pearson commented:

‘Four years have passed since Lee’s death. Finally, following his inquest, it has been confirmed to Lee’s family what they always knew to be true: that Lee was failed by HMP Swansea from the moment he entered the prison. The known risks to Lee of self-harm and suicide were not properly appreciated and steps were not taken to ensure his safety. We now know that those failings probably contributed to his death.

We hope that, following the damning conclusion of the inquest into Lee’s death, as well as the multiple critical reports by HM Inspectorate of Prisons into the early days care provided at HMP Swansea, lessons can be learnt. Families should be able to feel reassured that, when their loved ones enter prison, they will receive the level of care that they should rightly be able to expect.’

If you have questions over the treatment of yourself or loved ones in prison, please contact a member of our team today.