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Dean Saunders inquest: Jury finds serious failings in case Dean Saunders inquest: Jury finds serious failings in case
(about 2 hours later)
A prison inmate who killed himself "while the balance of his mind was disturbed, contributed to by neglect", an inquest jury has found. An inmate who killed himself and his family were "let down by a number of failings" by the prison system and mental health services, an inquest jury has concluded.
Dean Saunders, 25, from Basildon, died at HMP Chelmsford in Essex, in January 2016. Dean Saunders died at HMP Chelmsford in Essex in January 2016.
He had been arrested the month before when he stabbed his father during a paranoid episode. The 25-year-old had been arrested the month before, after his father was stabbed during a paranoid episode.
An inquest jury has found there were "a number of serious failings" in the way his case at the prison was handled. Care UK, the healthcare provider at HMP Chelmsford, announced it is to quit its contract at the prison.
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During the two-week inquest, witnesses told how decisions about keeping a watch on vulnerable prisoners had been made on a cost basis. It made the announcement after the jury's critical narrative conclusion.
The jury unanimously concluded that "financial considerations" were made in deciding to downgrade Mr Saunders from continuous watch status to half-hourly observations. The company said it had attempted to resolve issues at Chelmsford Prison but the level of resources the prison planned to make available were "insufficient".
The jury found Mr Saunders "and his family were let down by serious failings by mental health services and prison system". Mr Saunders, from Basildon, was a stay-at-home father, described by his friends as a "generous man" who loved his family.
It also found an assessment of his mental health needs was "not adequately conducted" and there were "multiple failings in recording and passing on information". He had been briefly held in a mental health secure unit in Rochford.
After he was released from hospital, he became "paranoid and confused" and attacked his brother and father in December 2015.
He was then charged with attempted murder.
The jury concluded he killed himself "while the balance of his mind was disturbed, contributed to by neglect".
The two-week inquest heard that he was unable to speak to his family while he was in prison because telephone numbers were taken down incorrectly.
The jury unanimously concluded that "financial considerations" were made in deciding to downgrade Mr Saunders from constant watch to half-hourly observations.
It said there were "multiple failings" including an "wholly inconsistent" review system and a "complacent" approach to Mr Saunders' state of mind.
The jury also found an assessment of his mental health needs was "not adequately conducted" and there were "multiple failings in recording and passing on information".
Mr Saunders was one of 102 inmates known to have taken their own lives at prisons in England and Wales in 2015.