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High suicide-risk prisoner Kieron Gray was 'failed' | High suicide-risk prisoner Kieron Gray was 'failed' |
(35 minutes later) | |
A "very serious failing" led to the death of a suicide-risk prisoner who killed himself on his first day in prison, an inquest heard. | A "very serious failing" led to the death of a suicide-risk prisoner who killed himself on his first day in prison, an inquest heard. |
Arsonist Kieron Gray, 42, from Blackburn, used a razor to kill himself in a shower at HMP Preston. | |
Prison officers had ignored reports that he was a suicide risk, Preston Coroner's Court heard. | Prison officers had ignored reports that he was a suicide risk, Preston Coroner's Court heard. |
Lancashire Probation Trust has since made changes to its procedures, coroner Dr James Adeley said. | Lancashire Probation Trust has since made changes to its procedures, coroner Dr James Adeley said. |
Lancashire Probation Trust compiled a pre-sentence report that said Mr Gray would be considered a "very high suicide risk" if he was sent to prison. | Lancashire Probation Trust compiled a pre-sentence report that said Mr Gray would be considered a "very high suicide risk" if he was sent to prison. |
'Failure to act' | 'Failure to act' |
The coroner highlighted the following failures: | The coroner highlighted the following failures: |
Dr Adeley said: "The failure of timely delivery, failure to act upon warnings sent and the lack of appreciation of information within the prison warning of an immediate risk was a very serious failing in the state's safe detention practices of prisoners." | Dr Adeley said: "The failure of timely delivery, failure to act upon warnings sent and the lack of appreciation of information within the prison warning of an immediate risk was a very serious failing in the state's safe detention practices of prisoners." |
His recommendations to change prisoner handling procedures will include a review of the system for recording receipt of risk of self-harm reports and whether those reports accompany the prisoner to prison. | His recommendations to change prisoner handling procedures will include a review of the system for recording receipt of risk of self-harm reports and whether those reports accompany the prisoner to prison. |
'Catalogue of errors' | 'Catalogue of errors' |
He is also calling for a review of disposable razors given to high-risk prisoners, the inquest heard. | He is also calling for a review of disposable razors given to high-risk prisoners, the inquest heard. |
Mr Gray, of Coleridge Street, set fire to his ex-girlfriend's flat, on Wellington Road, Blackburn, Lancashire, on New Year's Day after their relationship ended. | Mr Gray, of Coleridge Street, set fire to his ex-girlfriend's flat, on Wellington Road, Blackburn, Lancashire, on New Year's Day after their relationship ended. |
He was jailed for two years at Preston Crown Court in August 2011 after being convicted of arson with reckless endangerment to life. | He was jailed for two years at Preston Crown Court in August 2011 after being convicted of arson with reckless endangerment to life. |
Solicitors acting for Mr Gray's family criticised a "catalogue of errors" that led to his death. | Solicitors acting for Mr Gray's family criticised a "catalogue of errors" that led to his death. |
Kelly Darlington, from Farleys law firm, said: "The inquest into the death of Kieron Gray highlights a catalogue of errors in the way information is communicated and managed between organisations involved in sentencing an offender to prison. | Kelly Darlington, from Farleys law firm, said: "The inquest into the death of Kieron Gray highlights a catalogue of errors in the way information is communicated and managed between organisations involved in sentencing an offender to prison. |
She added: "These recommendations aim to ensure that custody is a safer place for prisoners who pose a high risk of self-harm." | She added: "These recommendations aim to ensure that custody is a safer place for prisoners who pose a high risk of self-harm." |
The coroner recorded a verdict that he took his own life. | The coroner recorded a verdict that he took his own life. |