19-Year-Old Found Hanged At HMYOI Brinsford In Wolverhampton Hours After Being Told He Could be Deported

The family of a teenager found hanged at a young offenders institute despite telling staff that he wanted to die, has called for lessons to be learned from his death.

Ondrej Suha, 19, from Walsall, was discovered hanging in his cell on December 21, 2015 hours after receiving a letter from the Home Office telling him he was liable to be deported to Slovakia, despite having lived in the UK since he was four years’ old. He was taken to New Cross Hospital in Wolverhampton but died on Christmas day.

His distraught family instructed expert civil liberties lawyers at Irwin Mitchell to investigate the events leading up to his death. They are also being supported by the charity Inquest and were represented in court by Tom Stoate of Garden Court Chambers. Four days before his death Ondrej had witnessed his cell mate try to hang himself.

A six day long inquest concluded today in Stafford, with the jury:

• Finding that Ondrej’s death was caused by being told that he could be deported just before being locked away for the night and therefore outside of the ‘core day’.
• Finding that the prison had breached Ministry of Justice guidance that an ambulance should be called immediately once a prison officer identifies that a prisoner’s life is at risk.
• Expressing concerns over the lack of training for prison officers.
• Expressing concerns over failures to communicate and coordinate clearly within the prison service in order to ensure continuity of care for Ondrej.

The Senior Coroner for South Staffordshire, Andrew Haigh, added that he would be sending a Regulation 28 Prevention of Future Deaths report to the head of the National Offender Management Service setting out his concern that inadequate training for night staff and a national policy allowing prisons to operate with only one CPR trained member of staff on duty at any one time could lead to future deaths.

Ondrej’s sister Andrea Suhova, said: “Our family has been devastated by losing Ondrej. Knowing that more could have been done to protect him has only made our pain worse.

“Ondrej grew up in the UK and thought of himself as British through and through. We will never understand why the prison thought it was appropriate to give him that letter, knowing full well it was informing him he might be deported, before locking him away for the night. He had only recently tried to harm himself and told staff that he wanted to die.

“It is now so important that the prison service, and HMYOI Brinsford in particular, learns from Ondrej’s death so that other young people are safe and other families don’t have to experience the same pain as us.”

Ondrej was remanded to HMYOI Brinsford on September 12, 2015 while awaiting trial for burglary and assault. He had sold property from his mother’s house while she was on holiday and slapped her on the wrist during an argument.

On November 30 he twice tied ligatures around his neck and pulled them tight. He tried to prevent staff from removing the ligatures and told them that he wanted to die.

Ondrej was placed on a suicide prevention and self-harm regime; however, this was cancelled the following day by a prison officer who later said that he didn’t know that Ondrej had tied two separate ligatures.

On December 7 Ondrej pleaded guilty and was given a 14-month custodial sentence. On December 17 Ondrej’s cellmate tried to hang himself while Ondrej was in the room.

Shortly before being locked in his for the night on December 21 Ondrej was served with Home Office papers advising him that he was liable to be deported following his sentence. The prison officer who served Ondrej with the papers told the hearing that he would have preferred to do this during the core prison day.

That night officers could not get a response from Ondrej who had partially covered the window in the cell door with toilet paper. There was a delay of several minutes before officers opened the door and found Ondrej hanged.

The inquest heard evidence that no one tried to resuscitate Ondrej until a nurse arrived seven minutes later and the control room officer did not call an ambulance until the nurse requested it. The inquest heard that his was in breach of national prison service guidance which states that an ambulance must be called immediately once a prison officer identifies that a prisoner’s life is at risk.

Paramedics arrived and took Ondrej to New Cross hospital in Wolverhampton where he died on Christmas Day with his mother and sister at his bedside.

Expert Opinion

“The failures in this case are depressingly familiar from other prison deaths. Whether because of poor training, understaffing or simple lack of care HMYOI Brinsford failed to keep Ondrej safe.

“This inquest has also heard worrying evidence that the prison service considers it is appropriate to allow prisons to operate with only one member of CPR trained staff on duty at any one time. Ondrej’s family now look to the head of the National Offender Management Service to act on the concerns of the Coroner regarding this policy.

"Our society needs to ask itself how many more prisoners must die before prison safety is made a priority.” Gus Silverman - Associate Solicitor

An investigation into Ondrej’s death by the Prison and Probation Ombudsman concluded:

• The suicide and self-harm prevention regime put in place on 30 November and cancelled the following day was “poorly managed and did little to support [Ondrej].”
• The decision to close the suicide and self-harm prevention regime on 1 December 2015: “underestimated Mr Suha’s risk so soon after his self-harm” and breached the requirement for such decisions to be taken following input from a multidisciplinary team
• “We have a number of concerns about the emergency response on the night of 21 December”. These included that officers “appear to have been confused about where to find the key” to Ondrej’s cell and failed to provide CPR. The PPO also expressed concern about the fact that the prison nurse did not have the necessary keys to attend the scene of the emergency but instead had to wait for prison staff to escort them, leading to further delay.

The Ombudsman made the following recommendations:

1. The Governor should ensure that prison staff manage prisoners at risk of suicide or self-harm in line with national guidelines, including that:

• First case reviews are multidisciplinary and always include a member of healthcare staff.
• Staff record information about all acts of self-harm in the ACCT [suicide and self-harm prevention] document.
• Case reviews assess risk in line with ACCT guidance
• ACCT plans are not closed at the first case review unless all issues identified at the assessment interview have been resolved.

2. The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that:

• All night staff carry individual emergency cell keys, enter cells as quickly as possible in a life threatening situation, and initiate basic life support promptly when needed.
• Control room staff call an ambulance as soon as an emergency code is broadcast.
• Healthcare staff are able to reach prisoners as quickly as possible when there is an emergency at night.