9 March 2018

Before HM Coroner D Hocking
Leicester Coroner's Court
26 February 2018 – 8 March 2018

The inquest into the death of Michael Dean Forster has concluded that neglect and several failings in care contributed to his death.  Michael, known as Mike, died on 21 November 2016 at the age of 26, having been discovered with a ligature around his neck on 19 November at HMP Leicester.

Mike suffered with psychosis and had a history of mental ill health. The inquest heard that in the months leading up to his death, he frequently expressed delusions including that he was going to be killed. Mike was remanded to HMP Leicester on 4 October 2016.

Upon arriving at HMP Leicester, suicide and self-harm prevention procedures (known as ACCT) were started. Mike was referred to the Mental Health Team and a psychiatrist. On 14 October had an appointment with a psychiatrist who believed Mike was psychotic and requested an assessment to commence the process of being moved to a secure hospital. Mike was still awaiting assessment at the time of his death.

During the inquest, evidence was heard that the prison psychiatrist had not started Mike on antipsychotic medication. They had requested to see Mike two weeks after the first appointment, but it took over a month before a second appointment took place on 18 November. Anti-psychotic medication was then prescribed but Mike never received it. Expert psychiatrist Dr Maganty said in evidence that the initial decision not to prescribe antipsychotic medication was a serious failing and, had Mike received it, his death might not have occurred.

Throughout Mike’s time in prison, his solicitors and family repeatedly informed the prison of their concerns about his health, after receiving concerning letters and Mike expressing plans of suicide during a visit. Mike’s risk level remained ‘low’ on the ACCT documents and it took weeks before the prison raised the observation levels from one per hour to two per hour. Despite this, prior to being found hanging, Mike went an hour without being checked on.

The jury found that had Mike received adequate care, observations, support and medication it is more likely than not Mike’s life would have been prolonged. They concluded that neglect by the mental health team contributed to Mike’s death. The narrative verdict by the jury also identified the following:

• The risk of self harm and suicide was inadequately communicated between healthcare and prison staff, and suicide and self-harm information was inadequately disseminated.
• Concerns raised by the family and Mike’s solicitor were inadequately acted upon, and there was ineffective recognition of Mike Forster's mental health deterioration by prison staff.
• There was a failure to apply the suicide and self-harm guidelines, with inadequate escalation of risk levels outline in guidance, and inappropriate management of ACCT procedures.

The jury found that the decision not to prescribe anti psychotic medication to Mike was inappropriate, and it was unreasonable for the mental health team to adopt a “wait and watch approach”. They believed Mike’s treatment should have been reviewed at his scheduled appointment and his mental health care plan was not implemented effectively. The observation and response to Mike's presentation in his cell on the morning of 19 November 2016 was inappropriate.

Michael’s family said: “We are all totally devastated by the loss of Mike. Mike was such a loving son, brother and dad and we have all lost our best friend. We will never get him back; however we feel the jury reached the right decision. Mike was neglected during his time in prison and it was so frustrating for us to know he was in there and that we were unable to help him any further.

Mike was so vulnerable and the prison and the healthcare had a duty of care to protect him.  It upsets us that Mike was left to suffer on his own, when the healthcare should have been adequately supporting him. Despite all the warnings we gave, Mike was failed and we will never forgive them for letting him down.  Mike shall always and forever be loved.”

Deborah Coles, Director of INQUEST said: “Michael’s entirely preventable death is a devastating indictment of a society which continues to imprison people for having mental ill health. Until this government properly invests in mental health provision, and stops the use of the so-called justice system for people in mental health crisis, these tragic and needless deaths will continue.”

Gemma Vine, Head of Civil Liberties at Minton Morrill Solicitors who represented the family said: “This is a tragic and deeply troubling case involving the death of a much loved young man whilst a prisoner at HMP Leicester which unquestionably should have been avoided. Michael’s death identifies serious flaws in the management of prisoners who are vulnerable because of their mental health and at risk of suicide, self harm.

We are pleased that the jury returned a damning conclusion identifying numerous failings and made a finding of neglect. The systems and attitudes that are currently operating are failing to protect the people in their care and these deaths will keep occurring until significant and meaningful action is taken by the Trust, prison and Ministry of Justice to make necessary changes.”

ENDS

NOTES TO EDITORS

For further information, please contact Lucy McKay on 020 7263 1111 or here.

INQUEST has been working with the family of Michael Forster since June 2017. The family is represented by INQUEST Lawyers Group members, Gemma Vine of Minton Morrill Solicitors & Ifeanyi Odogwu of Garden Court Chambers.