The death of a prisoner who hanged himself in Northern Ireland was predictable but information was not properly shared between staff, a watchdog has said.
Geoffrey Ellison, 58, was found in his cell in Magilligan, Co Londonderry, on March 28 last year, nine weeks before he was due for release.
He had received an upsetting letter from home in England which left him looking for new accommodation, the prisoner ombudsman said. The information was not passed to a senior manager or healthcare expert.
In an answerphone message left with the author of the letter, he said he was going to put a rope around his neck. By the time the person phoned the prison the following day to express concern, he was dead.
A reviewer for the ombudsman said: “Despite Mr Ellison’s past history and other risk factors being present ... it seems that information was not shared, or recorded systematically or appropriately between prison staff, or from prison staff to healthcare staff.”
Ellison had a history of self-harm and attempting suicide and a number of triggers and risk factors were present, yet a Supporting Prisoners At Risk (Spar) file was not opened.
The review noted the prison officer in the censor’s office had told the wing staff that the letter containing upsetting news was on the way to Ellison and advised the staff to keep an eye on him.
“The wing staff, although sharing this information verbally between themselves at the time, did not share or record it anywhere, pass the information on to oncoming staff, or consider escalating the information to a senior manager, or anyone in healthcare.
“Despite a number of risk factors described in the Northern Ireland Prison Service (Nips) Suicide and Self-harm Prevention policy, particularly previous suicide attempts, history of mental health issues and (upsetting news), being present, further action to monitor these risks was not considered necessary.”
During his time in custody, Ellison did not appear to be someone who was contemplating suicide. He had appeared content in Magilligan, got along well with staff and other prisoners and was actively planning to return home to England after release.
He lived in a low supervision area and worked as an orderly.
However, shortly before his death he received the upsetting letter from home.
One implication was that he might have had difficulty obtaining an address following release.
Although that concern was quickly dispelled, other important aspects of his future remained uncertain.
He tried to address them by phone but was unable to do so.
The report said: “Between March 23 and 26, Mr Ellison made 33 unanswered calls and left an answerphone message on almost every occasion.
“These messages again evidenced that he was becoming increasingly anxious, suspicious, frustrated and upset that his calls were not being answered.”
Two officers on his landing did not have undue concerns for Ellison as they thought his main anxiety about obtaining an address had been resolved.
After receiving the letter, other inmates said he smashed gifts which he had made to take home and ripped up photographs. However, they did not alert prison staff to Mr Ellison’s deteriorating mood, the report said.
It added: “While our clinical reviewer felt Mr Ellison’s death was predictable, she concluded that it could not be determined with any certainty that it could have been prevented.”
The report makes nine recommendations for improvement, all of which have been accepted.
Ombudsman Tom McGonigle said: “Mr Ellison was not believed to be at risk in terms of suicide and his death came as a shock to everyone who knew him at Magilligan.
“Suicidal ideation that had been apparent before he came into custody was not evident during this prison sentence.”