cell doorA “series of interconnected system inadequacies and failures” contributed to the death of 26-year-old Levi Cronin at HMP Highpoint, an inquest jury has concluded. 

Levi entered HMP Highpoint in August 2014 after a sentence for bike theft in April of that year. He had a history of mental health problems, which were known to the prison and was receiving treatment from prison mental health services.

In the inquest, the jury heard evidence that Levi was well-liked but sensitive and vulnerable. He took his own life on September 20, 2014. He was the fourth prisoner to die from self-inflicted injuries at HMP Highpoint between April 2013 and September 2014.

Inquests into the deaths of David Smith, Steven Trudgill and Callum Brown at HMP Highpoint all expressed concern at the prison's failure to learn lessons and provide a safe environment for vulnerable prisoners.

The jury recorded that there was a “series of interconnected system inadequacies and failures” which contributed to Levi’s death: 

Insufficient recording of information, for instance concerning Levi’s welfare

Insufficient communication between departments concerning Levi’s welfare

Inadequate staffing levels resulting in the failure of the offender supervisor to see Levi in good time and the failure to follow up referrals to the mental health team and arrange subsequent appointments

Inadequate support and supervision to the mental health team.

The Coroner will issue a prevention of future deaths report noting concerns around the recording and sharing of information by prison and healthcare staff.

Levi’s sister, Maureen, said: “We feel that Levi’s death was completely avoidable and it is a tragedy which has greatly affected our family. We are very grateful to the jury for the immense care they took in listening to the evidence throughout the inquest and their courage in providing their conclusions. We implore those responsible for caring for vulnerable people in custody to heed the jury’s concerns so that such deaths might be avoided in future.”

Lawrence Barker from Bindmans Solicitors, acting on behalf of Maureen Cronin, added: “The jury’s conclusions in Levi’s case highlighted areas of very significant concern that were common across the four self-inflicted deaths that occurred at HMP Highpoint during an 18-month period. Both the prison and the prison healthcare provider repeatedly asserted that lessons have been learnt and improvements made, however it is clear from the areas identified by the Coroner for his Prevention of Future Deaths report that serious concerns remain around the treatment being provided to vulnerable individuals. It is the hope of the family that there might now be meaningful change.”

Deborah Coles, director of INQUEST, said: “Sadly there is nothing new about these findings - the same systemic failings are reported month on month. How many more warnings about the perilous state of prisons are needed from jury findings at inquests, coroner’s reports, prison inspection and monitoring boards and prison staff? Why are these warning never acted upon?”

INQUEST has been working with Levi’s family of since 2014. The family is represented by INQUEST Lawyers Group members Lawrence Barker from Bindmans Solicitors and Jesse Nicholls from Doughty Street Chambers.