The Article 2 inquest touching on the death of Matthew Pearson who was found dead in his prison cell concluded on the 13th October 2022. The jury concluded that Mr Pearson’s death was suicide.

Dr Graydon of 33 Bedford Row Chambers London represented the deceased’s mother. The other interested persons represented at the inquest were HMP Ranby and Nottinghamshire Healthcare NHS Foundation Trust.

During the 8 day inquest (from the 4th to 13th October 2022) conducted by the Area Coroner (Miss Bower) at Nottingham City Council building, the jury heard substantial and detailed evidence surrounding the circumstances of Mr Pearson’s death. This included significant evidence from police, prison staff at HMP Ranby, as well as from heath care staff at Nottinghamshire Healthcare NHS Foundation Trust. The witnesses were questioned in considerable detail by the coroner Miss Bower. Significantly they were also questioned by Dr Graydon as required throughout the 8 days.

Mr Pearson had a history of self-harm and had been placed on an ACCT (Assessment by the Care in Custody and Teamwork) Plan by prison staff at another prison (HMP Nottingham) before being transferred to HMP Ranby. The ACCT Plan is used by prison staff nationally to plan support for prisoners who are at risk of self-harm or suicide. The primary purpose of the ACCT Plan is to keep the prisoner safe.

Significantly, the jury concluded, amongst other inadequacies, (see below) that Mr Pearson’s ACCT plan was not managed in accordance with the national Prison Service Instruction (PSI).

Circumstances of Mr Pearson’s Death

In addressing in what circumstances the deceased came by his death the jury concluded that:

“Matthew Pearson was a prisoner at HMP Ranby, in Nottinghamshire, where he was discovered deceased in his cell, House Block 2 North, cell 14, at around 07.30 hours on 8 January 2020.

Matthew had died as a result of hanging by ligature suspension. Matthew had ingested a potentially fatal dose of both methadone and citalopram at sometime during the evening of 7 January 2020, whilst he was locked in his cell.

Matthew was last recorded alive in the ACCT care plan document at 06.00 hours on 8 January 2020. Time of death occurred somewhere between 06.00 hours and 07.15 hours on 8 January 2020, when a code blue was called by prison staff.

Matthew was vulnerable by way of his mental health and self-harm issues and was therefore at risk of self-harm and suicide, and was placed on an ACCT, which required him to receive three meaningful conversations and three random nightly checks.

Matthew had left two "last notes" or letters of intention in a prominent location in his cell which stated his clear mental health distress and were addressed to his Mother and Son, declaring his intentions to end his life.”

While the jury’s conclusion was that Mr Pearson’s death was suicide, significantly they also concluded that there were a range of inadequacies, failings and missed opportunities surrounding the ACCT plan for Mr Pearson, his self-isolation in prison, and his mental health.

ACCT Plan

Although the primary purpose of the ACCT Plan was to keep Mr Pearson safe, the jury concluded that:

(i) Mr Pearson’s ACCT plan was not managed in accordance with the national Prison Service Instruction.

(ii) Specific acts or omissions did probably more than minimally contribute to his death.

(iii) In particular, the jury concluded that there was:

“Inadequate assessment of risk of suicide and self-harm”

“Inadequate implementation of National Prison Service Instruction”

“Acct case reviews were not multi-disciplinary”

“Inadequate communication between all relevant parties”

Self-Isolation

Turning to Mr Pearson’s continuing self-isolation, the jury also concluded that:

(i) His self-isolation was not managed in accordance with the national and local CSIP (Challenge, Support and Intervention Plan) framework?

(ii) Specific acts or omissions did probably more than minimally contributed to his death.

(iii) In particular, the jury concluded that there was a:

“Lack of continuity of care between professionals”

“Failure to address ongoing self-isolation”

“Consistent missed opportunities to refer Matthew for appropriate mental health support"

Mental Health

Finally, in addressing the issue of Mr Pearson’s mental health care, the jury concluded that:

(i) He was not offered a timely mental health assessment following the referral on arrival to HMP Ranby on 27th December 2019.

(ii) There were missed opportunities to have expedited a review of his mental health.

(iii) Specific acts or omissions did probably more than minimally contributed to his death.

(iv) Here again the jury concluded that there was;

“Insufficient input by mental health to ACCT reviews”

“Ongoing delay of mental health assessment”

(Underlining has been added for emphasis)

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Dr. Graydon was instructed by the solicitors representing the deceased’s mother.

Dr Graydon is a very experienced and accomplished inquest advocate. In addition to representing families he also represents the entire range of interested persons in Article 2 and non-Article 2 inquests.

He has a particular interest in Article 2 inquests and is available to provide representation at inquests and pre-inquest review hearings through his senior clerk Mark Byrne.