Neglect contributed to the death of a young father in HMP Chelmsford, who was taken into custody when he was in severe mental health crisis, a jury has concluded.

The jury found that Dean Saunders and his family were “let down by serious failings in both mental health care and the prison system” and said that Care UK, the private company that runs healthcare at the prison, “treated financial consideration as a significant reason to reduce the level of observations” of Dean, despite repeated warnings of his state of mind.

They concluded that Dean took his own life while the balance of his mind was disturbed and that the cause of death was “contributed to by neglect”.

Dean, 25, was found dead on January 4, 2016. It was his first time in prison. Dean showed signs of acute mental ill health in the days before his imprisonment. He was taken from his home by the police on December 16, 2015 after an incident during which he tried to take his own life. At the police station, he was not detained under the Mental Health Act and transferred to hospital. Instead, he was charged and subsequently transferred to HMP & YOI Chelmsford.

The 2-week inquest into his death before a jury and HM Senior Coroner for Essex, Caroline Beasley-Murray, heard evidence from a number of individuals that when taking decisions about prisoners’ levels of observations, the head of healthcare took into account her budget and financial considerations – a claim strongly denied by her.

The inquest jury found that a number of serious failings led to Dean’s death, including: 

Inadequate mental health assessments at Basildon Police Station and in HMP Chelmsford, where the results of the assessment were described as “predetermined” and medical or mental health professionals were not present

The head of healthcare at the prison, an employee of Care UK, “treated financial consideration as a significant reason to reduce the level of observations” of Dean

An “inadequate” response by HMP Chelmsford to the family and “multiple failings” in recording information pertinent to Dean’s situation

An “absence of clinical leadership” in the healthcare wing of HMP Chelmsford

A “total lack of consistency and logic regarding the level of risk ascribed to Dean’s situation” and “perfunctory” observations.

The jury said it was unclear whether sufficient enquiries were made to find Dean a mental health bed out of the local area and said: “While we do not believe that the result of the assessment itself was predetermined, the pathway to prison was.” The first available bed following Dean’s arrest on December 16 was on January 4 – the day he died.

The jury said the inquest was an “extremely challenging case” and expressed their “sincere condolences” to Dean’s family.

In a statement, Dean’s family said: “The jury’s damning indictment is not the end of our journey. It is the start of our mission to ensure that the changes we, and previous families, have been promised are embedded in real practical action and true accountability. This means a fundamental change in how mental illness is perceived and treated. Hospital, not prison, is where Dean deserved and needed to be. We as a family, together with our lawyers and INQUEST, want Dean’s death to mark the end of empty promises and the start of change.”

Deborah Coles, director of INQUEST, said: “Dean Saunders, a young father in serious mental health crisis, should never have been in prison in the first place. His death was entirely preventable. The responsibility for his death lies with a system that criminalises people for being mentally ill. As a society, we should not accept that deaths such as Dean's are inevitable: they are not. Time and again, we hear the empty words “Lessons will be learned”. Without action and accountability, nothing will change. Until this government properly invests in mental health provision, and stops the use of prison for people in mental health crisis, these tragic and needless deaths will continue.”

Charlotte Haworth, Dean’s family’s solicitor, said: “Dean’s death was yet another example of the warnings of a loving family being ignored by professionals. There were repeated claims during the inquest that the healthcare wing at Chelmsford prison was a place of safety for Dean whilst he waited for transfer to hospital. The jury’s findings clearly show that it was not. There needs to be immediate action by the authorities to ensure that those in mental health crisis are diverted away from the criminal justice system and that essential mental health beds are available.”