Coroner's concerns over lack of 'safer cells' at HMP Leeds more than two years after prisoner's death

James Hargan, West Yorkshire eastern assistant coroner, issued a prevention of future deaths report following the inquest into the death of 40-year-old Wayne Boughen.

The inquest heard Mr Boughen was found in his standard cell just after 12.30am on November 16 2018 and died at Leeds General Infirmary the following day

The inquest jury was told no-one else was involved in his death.

In the prevention of future deaths report, Mr Hargan wrote: "At the time of Wayne Boughen’s death, HMP Leeds did not have any cells which were certified safer cells (anti-ligature cells) in accordance with national standards.

"HMP Leeds still does not have any such certified safer cells.

"HMP Leeds has a small number of cells which have an increased level of safety as compared with the majority of cells within the prison, but even they do not comply with the certified safer cell standard."

Mr Hargan added in the report: "In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action."

Last month, an inquest jury concluded Mr Boughen had hanged himself, but were unable to determine his intention.

The medical cause of death was hanging.

The inquest heard that in the five weeks before his death there had been incidents of self-harm, threats of suicide and a claimed suicide attempt.

And the inquest was told there was a missed visit from his mother in the days before his death.

The report states: "The reasons for the cancellation of this visit were unclear. Wayne had stated the importance of this relationship to his well-being."

The report states that no reason has been established why a psychiatric evaluation of Mr Boughen planned for the 14th did not take place.

Mr Hargan said in the report that there was an open ACCT document (Assessment, Care in Custody and Teamwork), which required hourly irregular observations.

The report states: "Prison officers differed in their interpretation of ‘hourly irregular observations’ e.g. whether that required a maximum of 60 minutes between observations."

The report states that family members and fellow prisoners had raised concerns about Mr Boughen's mental health in the weeks before his death.

A Prison Service spokesperson said: “Our thoughts remain with the family and friends of Mr Boughen.

"We will consider the Coroner’s comments carefully and respond in due course.”

In April, a coroner issued a prevention of future deaths report after an HMP Leeds inmate with terminal cancer died in an ambulance “effectively trapped” at the prison gate.

Senior West Yorkshire (East) Coroner Kevin McLoughlin sent the Regulation 28 report to the governor of the jail at Armley following an inquest into the death of 73-year-old Guy Clifton Paget.

The inquest at Wakefield Coroner’s Court heard that serving prisoner Mr Paget was diagnosed with terminal cancer of the oesophagus in December 2020.

Mr Paget was found in a confused state in his cell in the prison’s hospital wing at around 1pm on March 16 this year.

Mr McLoughlin wrote in the report: “The clinicians responsible for his care decided he should be taken to an outside hospital for treatment.

"An ambulance was duly brought into the prison. The ambulance could not convey Mr Paget to hospital, however, due to incorrect paperwork being available at the prison gate, which delayed the authorisation for it to leave the prison.” Mr McLoughlin said he believes there was a risk that future deaths could occur unless action is taken.

He wrote in the report: “The prison should have effective systems to facilitate the exit of an emergency ambulance from the prison.”

A Prison Service spokesperson said in connection with that report: “Our sympathy goes out to Mr Paget’s family and friends and we will respond to the coroner’s recommendations, in detail, shortly.”

“The prison should have effective systems to facilitate the exit of an emergency.”