An former British Army soldier who hanged himself in jail might still be alive if staff had taken his shoelaces, an inquest jury found today.
Even though Duncan Brown, 23, tried to commit suicide by hanging himself with his laces at Northern Ireland’s high security Maghaberry Prison weeks earlier, warders supervising him were not told.
This communication breakdown played a part in his death last November, a jury at Belfast Coroner's Court decided.
As the damning assessment was delivered, Brown’s anguished parents, who travelled from their home in Leicestershire, savaged the prison regime.
“If all this had been carried out our son would still be alive,” his adoptive mother Jo said. “He was allowed to die.”
Brown, who served with the Royal Logistics in Derry, had been remanded to the jail to await trial on indecent assault charges following an alleged incident in the city.
He was confined to a 23-hour lock-up in a special unit after allegedly assaulting three warders.
Despite a history of self-harm, prison staff who examined him hours before he killed himself did not believe him to be vulnerable.
During the inquest Brown’s adoptive father, David, questioned Maghaberry staff.
He told medical officer Archie Parker: “I find it disturbing that you met with Duncan in the morning in your professional duties and you said there was no problem, and also in the afternoon you spoke with him and considered professionally in your opinion he wasn’t at risk.”
Mr Parker insisted there was no indication that Brown would harm himself.
Prison psychiatrist, Dr Ian Bownes, said even the most rigorous checks do not always detect the imminent dangers.
“There’s always going to be a discreet corner of a person’s world that is inaccessible,” he told the inquest.
Greater Belfast Coroner, John Leckey, commented that Brown’s emotional state seemed to go into a “downward spiral” once he joined the Army.
“He appeared to have a very happy childhood and adolescence,” Mr Leckey said. “He was brought up in a very loving family environment.
“It seems to be the time he joined the Army that was the catalyst for him going into this downward spiral.”
After returning a verdict of suicide, the 11-member jury listed a series of defects in the prison regime which played a part in the tragedy.
As well as the failure to remove shoelaces and staff not being alerted to a previous suicide bid, Brown’s isolated confinement and the decision to cut medication he was taking after two weeks were criticised.
The jail’s failure to implement an HM Inspectorate of Prisons recommendation to introduce a new risk assessment procedure at Maghaberry 18 months previously also came under fire.
Following the verdict, Mr Brown said: “It’s not rocket science to realise someone who tried to commit suicide with his shoelaces shouldn’t be allowed to do it again.
“And how did a professional see Duncan twice that day yet exactly two hours later he was hanging from a curtain rail ?”
The Northern Ireland Prison Service responded by saying a new suicide and self-harm prevention policy was introduced in March.
“After every death in custody we carry out a review of procedures to make sure we have learnt all the lessons that could be learnt from that incident,” a spokesman said. “That was done in this case.
“We are already conducting a review of deaths in custody to make sure our policy is the most appropriate and fit for purpose it can be.
“And we will be studying the coroner’s findings carefully to see what future actions we might need to take.”