A jury has concluded that Shaine, an IPP prisoner, described by his family “as a loving and calm person”, died by suicide on 01 November 2022, at the age of 34, after feeling ‘forgotten by the system’ due to his IPP sentence and felt he was being punished for his mental health. His inquest was heard at the Leicester City & South Leicestershire Coroner’s Court between 18 – 28 June 2024 before HM Area Coroner Ivan Cartwright with a jury.

Shaine had struggled with his mental health from an early age and was diagnosed with ADHD at the age of 10. He entered the prison system at the age of 17 and received an Imprisonment for Public Protection (‘IPP’) sentence. On 01 January 2022, Shaine was remanded at HMP Lewes in East Sussex. During his time at HMP Lewes, Shaine suffered a deterioration in his mental health and on 15 June 2022, following his sentencing performed a serious act of self-harm whilst located in the Care and Separation Unit (“CSU”), requiring hospitalisation. Shaine strongly believed that he should have been in a secure hospital environment in order to receive treatment for his mental health problems, as Shaine believed that his symptoms were that of Paranoid Schizophrenia. However, despite several referrals, Shaine was refused admission to a secure hospital.

On 23 September 2022, Shaine was transferred to HMP Gartree in Leicestershire. During evidence heard at the inquest, the reasons given for the transfer to this prison estate was because this prison only houses prisoners serving indeterminate sentences, and HMP Gartree also offers specialist units named ‘Psychologically Informed Planned Environments (‘PIPE unit’)’ designed to support those individuals with complex needs. However, at the time of transfer, Shaine was not suitable for HMP Gartree’s PIPE unit and the move meant that Shaine – who lived in Bognor Regis and was extremely close with his family – was far from home, and family members were unable to visit him. His family were a strong protective factor for Shaine’s mental health. Staff at HMP Gartree were not aware that Shaine was arriving on this date, and staff were not aware of the reasons for Shaine’s transfer. In a separate investigation conducted by the Prison & Probation Ombudsman (‘PPO’), they found that HMP Lewes did not complete a handover form regarding Shaine’s mental health needs and reiterated the need for “a formal clinical handover […] for all complex mental health prisoners before transfer to a new prison.” The PPO considered this to be a failing on behalf of HMP Lewes.

Whilst at HMP Gartree, Shaine remained on an Assessment, Care in Custody and Teamwork (“ACCT”) document due to his risk of self-harm. During his ACCT assessments with his case manager, Shaine presented as anxious and fidgety, he made limited eye contact and was presented as unkempt. It was documented within prison records that a decline in his physical appearance was a sign of his mental health deterioration. Despite demonstrating these unusual behaviours, Shaine’s ACCT document was closed on 11 October 2022. Some days later, Shaine tested Covid-positive, and he was placed in isolation within his cell. On 23 October, his ACCT was re-opened due to threats made by Shaine to self-harm due to his being in cell-isolation for eight days. The jury also heard evidence that Shaine had recently written a note stating that he still wanted to kill himself and that he was worried that he would do so, but that members of prison and healthcare staff conducting Shaine’s ACCT reviews had not been made aware of this. An ACCT review was conducted on 27 October 2022, and again the decision was made to close Shaine’s ACCT. The nurse who contributed to the decision to close Shaine’s ACCT on 27 October stated in evidence, that on reflection it is possible that it would have been prudent to keep Shaine’s ACCT open for longer. The PPO concluded that Shaine’s ACCT document should have been kept in place “until staff had more information about Mr Tester’s complex mental health and personality disorders.” A Forensic Psychiatry appointment had been scheduled to take place on 16 November.

On 31 October 2022, Shaine made a number of concerning phone calls to family members, during which he was not making sense and was sounding increasingly unwell. Shaine’s family recognised this as a deterioration in his mental health. At 21:34, Shaine’s mother rang HMP Gartree’s Safer Custody Hotline and left a message on the system to express her concerns and ask that a member of staff check on Shaine in his cell. This call was picked up by a Custodial Manager at around 01:42 on 01 November 2022, and the staff member requested that Shaine be checked on by the night patrol.

At approximately 01:45, a night patrol officer attended Shaine’s cell and found him unconscious following a serious act of self-harm. Shaine had also barricaded his cell. The officer put out a Code Blue via the radio, and an ambulance was called. The jury heard evidence of how it took nearly 40 minutes for the ambulance service to be told that Shaine was in cardiac arrest and that prison staff were unclear as to who should have relayed this crucial information. Paramedics arrived at Shaine’s cell at 02:49, and he was sadly pronounced deceased at 02:53 on 01 November 2022.

The jury concluded that:

“the intention behind Shaine’s fatal actions in the late hours of 31 October into the early hours of 01 November is inconclusive [however] the balance of probability is that Shaine did intend to take his own life in an act of suicide.”

Shaine was heavily affected by his IPP sentence, and this had a severe impact on his mental health, which he voiced to several members of prison and healthcare staff. Although the IPP sentence was abolished in 2012, thousands of people subject to such a sentence are still in prison. As of December 2022, there had been 78 IPP self-inflicted deaths since the sentence was introduced in April 2005. Shaine was one of nine IPP prisoners to take their own life in 2022 alone.

The PPO concluded that Shaine:

“did not receive an appropriate level of mental health care during him time at HMP Gartree.”

Shaine’s family were represented by Nicola Miller of Broudie Jackson Canter Solicitors, and Rachel Woodward of Doughty Street Chambers. Commenting on the inquest conclusion, Nicola Miller said:

“This has been an extremely tragic case as it is clear that Shaine was failed by the system in respect of his IPP sentence, and that he was not provided with the appropriate support for his mental health. We are encouraged by the changes the Ministry of Justice have made to the system following Shaine’s death, and we hope that lessons have been learnt to prevent this tragedy happening again.”

Shaine’s mother Gaynor and brother Jack said:

“The past two years have been extremely difficult, and we are relieved that Shaine’s inquest has now concluded. As a family, we are satisfied to hear the changes that have been made within the prison system. We will continue to fight for justice for other prisoners who remain on the IPP sentences and ensure that they will not be forgotten. Shaine was extremely intelligent and had so much potential. He was a very gentle and quiet soul, who was looking forward to his future outside of prison. We miss Shaine every day, and I still can’t believe he is gone. Shaine made my life complete, and I will always be glad that I had the pleasure of being his mum.”