Following a five day inquest at Doncaster Coroner’s Court, a jury found that the failures of Serco and Nottinghamshire Healthcare NHS Trust to deal with bullying, violence and substance abuse at HMP Doncaster were causative of the death of 42 year old Gerard Scahill on 22 April 2016.

Gerry was a vulnerable man with a long history of mental health issues and substance abuse, who was serving a nine year sentence at HMP Doncaster.

On his entry to HMP Doncaster in October 2015, prison and healthcare staff were made aware of threats to Gerry by prison gangs, and during his stay became aware of his use of the drug “spice” and his history of mental health issues.

During his stay, Gerry made sure to raise concerns about his welfare to prison staff. On three occasions, in the period leading to his death, he reported to the prison staff that he was under threat and scared for his safety. On one occasion, he had to be returned to his wing under prison escort and he subsequently refused to leave his cell for two days. Notwithstanding his reports, there was no record that prison staff conducted any investigation, or put in place any safeguards for Gerry.

The jury heard new psychoactive substances (NPS) known as “spice” are currently rife in prison. Studies suggest that “spice” and other NPS’ exacerbate mental health conditions such as depression, anxiety and can lead to self-harm and debt. On 23 March 2016 staff found Gerry possibly under the influence of “spice”. He also reported to healthcare staff that he was taking NPS on most days, and as much as he could “get hold of”. Despite this, he was never referred to the substance misuse team, who were able to offer psychotherapy treatment for NPS use.

On 22 April 2016, Gerry was found hanged in his cell. Though both Prison Officers and paramedics attempted to revive him, they were unsuccessful.

In a narrative conclusion critical of the prison, it was found that:

• Nottinghamshire Healthcare NHS Trust did not adequately and effectively manage Gerry’s use of spice and this was causative of his death.
• That Serco prison staff did not adequately and effectively manage the threats and bullying that Gerry was subject to, and that this was also causative of death.
• There were non-causative failures regarding training of Prison Custody Officers on the unlock procedure.

The jury could not be certain that Gerry intended to kill himself.

Gerry’s family are understandably devastated by his death but are pleased that the jury identified the failings that led to Gerry’s death. They hope that HMP Doncaster, private prison providers and contractors, and the wide prison service will now implement changes to ensure that incidents like this are not repeated.

Jenny Fraser, solicitor for the family, said

“Sadly this is yet another death at a private prison, and it’s welcome that the jury have clearly identified the significant failings of both Serco and Nottinghamshire Healthcare NHS Trust towards the people in their custody.”

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.