The Ministry of Justice has accepted there were significant failings in the care given to a prisoner at HMP Leeds who took his own life while in segregation.
It follows critical findings recorded at the end of a three-week inquest into the death of 37-year-old Chris Beardshaw on December 30, 2013.
Jurors at Wakefield Coroners Court heard how Mr Beardshaw became distressed after complaining about the condition of his cell in the prison’s segregation unit.
He went on to make around 40 cuts to his arm using the plastic knife provided for his meal, triggering a number of actions by prison staff to address concerns for his safety.
However, the measures failed to stop Mr Beardshaw taking his life later that day.
A ministry spokesman said: “This is a tragic case and our thoughts are with Chris Beardshaw’s family and friends.
“The safety and welfare of people within our custody is our top priority but we recognise that there were significant failings in his care.
“We will carefully consider the findings of the inquest, and make sure all necessary measures are in place to better support offenders.”
The inquest heard there had been no previous concerns about Mr Beardshaw’s mental health, but he became distressed about the condition of the cell he was placed in.
After Mr Beardshaw cut himself, staff opened an Assessment, Care in Custody and Teamwork (ACCT) Review to note concerns about his mental health. They also removed furniture and replaced his clothes with what officers believed was anti-tear clothing.
But the jury noted a number of issues on Thursday as it returned a narrative verdict, which set out the events leading to Mr Beardshaw’s death.
The jury highlighted concerns around staff training, the quality of ACCT observations and communication between officers, and evidence that one officer had failed to check on Mr Beardshaw as recorded.