Inquest into mentally ill prisoner’s death finds failures in prison healthcare at HMP Stoke Heath
28 October 2014
A jury at the inquest into the death of a 26-year-old father of three from Birmingham who died whilst in custody at HMP Stoke Heath, has found that a number of failings by the prison’s mental health services contributed to his death, including failure to access medical records, failure to adequately monitor the prisoner and failure to respond appropriately to his deteriorating condition. His death highlights the continued failure of the prison system to deal effectively with prisoners with mental health problems at a time when self-inflicted deaths among inmates have risen by 69%.
Mohammed Naveed Zaber, known as Naveed, had a history of mental health problems, including diagnoses of schizoaffective disorder and other psychotic symptoms. He died on 25 March 2013 in hospital having been found three days earlier hanging in his cell.
In the run up to his death, Mr Zaber smashed his television and used the glass to cut his arms. He was placed on suicide / self-harm monitoring and moved to another wing but his behaviour continued to deteriorate. He drank washing-up liquid, swallowed batteries, was noted to be making ligatures from his bedsheet on several occasions and was reported to have red marks around his neck. He repeatedly asked to see a psychiatrist and to be prescribed medication and also made comments suggesting possible psychosis, including that he believed a device in his chest was transmitting his thoughts. He also reported he was being bullied.
Despite his escalating behaviour he was not seen by a psychiatrist during the period immediately prior to his death.
The jury determined that Mr Zaber took his own life using a ligature but were unable to determine his state of mind at the time at which he did so. They catalogued a number of failings in the care of Mr Zaber:
- The inreach services which provide care for more seriously mentally ill patients, failed to access all of his medical history and therefore were not in a position to make a fully formed decision of his mental health, wellbeing and subsequent treatment plan;
- Inreach failed to take a cautious approach when reducing medication; and
- There was a failure to adequately monitor Mr Zaber after reduction and stopping of his medication and a failure to respond appropriately when he began to deteriorate.