A prison has been told to review its training after a young inmate killed himself just 48 hours after being locked up.
Simon Faherty was remanded in custody to HMP Elmley in Eastchurch, Sheppey, in November 2023, after being charged with possession of Class B drugs, criminal damage, affray and possession of an offensive weapon.
On November 20, 2023, the 20-year-old was found hanged in his cell with the Prison and Probation Ombudsman’s report noting “missed opportunities” to identify him as at risk of suicide and self-harm.
In Mr Faherty’s personal escort report, a document which aims to ensure the safe and secure movement of prisoners, it said he was being assessed for bipolar but was not seen to be at risk, although it mentioned he should be checked every 30 minutes. This document was not seen by Elmley staff upon his arrival.
He was also unable to call home after arriving at reception with a dead phone battery, with no chargers available for him to use at the time, so he did not have access to his contacts.
In further assessments by prison staff, the 20-year-old was found to have no risk factors despite his young age and it being his first time in prison.
Three hours later, Mr Faherty got into a fight with a cellmate and was later moved to a single-occupant cell.
The Prison and Parole Ombudman’s report added: “No one recognised that this might increase his risk and there was limited follow-up engagement from staff who did little to demonstrate concern for his welfare in the aftermath.”
Two days later, on November 20, Mr Faherty attended an adjudication hearing into the brawl but did not receive his standard prison induction, and no reason was provided for this.
The report noted this would be “especially important for a young man who had not previously been to prison and who arrived over the weekend”.
At 7.22pm Mr Faherty sounded his cell bell alarm and spoke to an officer for 18 minutes, stating that he missed his family and was given advice on making a call.
It was noted that this was the longest and likely most supportive contact an officer had with him.
But an hour later, he was found hanged in his cell, and a general alarm was sounded with staff beginning resuscitation attempts.
However, the report said this was not immediately called as a “code blue” and emergency services were not informed they were attending a hanging.
Health care providers arrived at 8.47pm and continued chest compressions but confirmed he had died at 9.22pm.
The report raised concerns over the handling of the situation that would ultimately impact Mr Faherty’s care.
It stated: “There were some missed opportunities to identify Mr Faherty as at risk of suicide and self-harm. Some recognised he had risk factors, whereas others told that they did not think he had any at all.
“No one recognised that having a fight within a very short time of arrival in prison might increase Mr Faherty’s risk.
“There was a lack of meaningful engagement with Mr Fahery in his 48 hours at Elmley, and he did not receive a prison induction in line with expectations.
“Communication at the scene was poor. Staff in the control room did not tell the ambulance operator that Mr Faherty had been found hanged.
“Prison staff at the scene did not tell their healthcare colleagues, and no one told paramedics immediately upon their arrival, which affected the initial care he was provided.
“As highlighted by the clinical reviewer, the body worn camera footage shows a disjointed and chaotic approach in delivering emergency care with multiple staff members in the confines of Mr Faherty’s cell.”
Several recommendations were left to be considered, including that the governor and head of healthcare review the training for reception and induction staff to ensure appropriate support is provided to those at risk of self-harm and suicide.
It also stated the process should be reviewed to understand why staff did not see Mr Faherty’s personal escort report and how this information should be used during the first night’s screening.
An analysis of the emergency response was also requested to rectify the issues presented during the situation after Mr Faherty was discovered.
