A jury inquest at Liverpool Coroner’s Court has made a damning conclusion that bullying, debt and drug abuse within HMP Liverpool exacerbated the conditions that led to the suicide of John Neil Duffey.

John, a former Corporal in the Royal Green Jackets and a veteran of tours of duty in Northern Ireland, was discovered hanging in his cell on 16 July 2016, whilst a prisoner on HMP Liverpool’s J Wing.

During his military service, John began to suffer from Post-Traumatic Stress Disorder (PTSD). In 2000 he attempted to hang himself, and was discharged from the armed forces on medical grounds. The family advise that in 2011, John made a further attempt to hang himself. When they returned to the UK, John was admitted to Arrowe Park Hospital.

Since leaving the military and whilst dealing with his mental health issues, John fell into a pattern of alcohol and drug abuse.

In 2015 he was remanded in custody at HMP Liverpool, and whilst here engaged with the “Journey to Recovery” (J2R) programme (a six month intensive programme helping at risk prisoners to deal with substance abuse issues). The jury heard evidence that drugs were available on the J2R recovery wing. John also used the psychotherapy services offered by Lancashire Care NHS Trust at the Prison. The jury heard evidence that healthcare staff within the prison were not equipped to provide treatment for PTSD due to staff vacancies. No attempts were made by the prison or healthcare staff to contact John’s support worker in the community.

The jury heard John fell into debt with other prisoners, which led to bullying and threats. On several occasions he informed staff that he was being threatened for debts, and identified the other prisoners. On 7 November 2015, he was found in his cell with self-inflicted cuts to his wrist and in possession of a ligature. He told prison officers that he had self-harmed due to his debt. An ACCT (Assessment, Care in Custody and Teamwork) was opened. The ACCT is a procedure to support prisoners at risk or in crisis. This ACCT was closed on 13 November 2015, as prison and healthcare staff judged the risk to John had sufficiently diminished. There was no investigation into John’s reports of threats and the perpetrators were not challenged.

John completed the J2R programme, was given valuable and trusted roles within the prison, as a wing cleaner and in an ad hoc role assisting other troubled prisoners. The jury heard evidence that John continued to fall into debt with other prisoners. He relapsed into drug use, becoming a user of spice.

On 16 July 2016, John was found hanging in his cell by his cellmate. Prison officers cut him down, commenced CPR and an ambulance was called which took him to Aintree Hospital. That evening, he was pronounced dead.

Following a five day inquest, on 23 November 2017, a jury concluded that John had intentionally killed himself, and that his suicide was due to his mental health issues, and that these were exacerbated by the bullying, debt and drug use. The jury also found that the lack of a PTSD specialist was a missed opportunity.

Representing the family, a solicitor at Broudie Jackson Canter, said

“It is intolerable that Inquest after Inquest criticisms of HMP Liverpool have been identified by juries. Despite this there is no evidence of any changes being made to prevent future deaths. Where there is a culture of denying there is a problem, then there will be no change. We once again urge HMP Liverpool and the Prison Service as a whole to accept that this is a prison system in crisis.

The Former Bishop of Liverpool’s report published earlier this month identifies the issue of ‘Institutional Defensiveness’. We would urge HMP Liverpool and other institutions to approach these tragic cases with a recognition that change is needed.”

John’s family have advised that they are grateful for the conclusion given by the jury, and hope that the prison and the healthcare provider take steps to stop this from happening again.