A coroner has highlighted prison failings after an inmate who stabbed a stranger to death in 2013 was found dead in his cell.
Stephen Sleaford was found unresponsive on 27 October 2022, after taking his own life at HMP Gartree, near Market Harborough in Leicestershire.
Following an inquest, held in September, it was concluded that “due to failings of the prison system, not following the adequate protocols, Stephen was unable to receive the healthcare and support he required”.
Coroner Ivan Cartwright has now issued a call for action to prevent future deaths at the prison in a report, and raised a number of concerns.
Sleaford had been serving a life sentence for murdering stranger Janusz Smoderek, 48, who had sexually assaulted a woman in 2011.
During his sentencing at Lincoln Crown Court, a judge said the woman had been rescued and was “in no danger” when Sleaford carried out the attack.
The 49-year-old, from Boston in Lincolnshire, had served 11 years of his 23-year minimum term at the time of his death.
According to Mr Cartwright, the inmate had complained of health problems, including mental health issues while at the category B prison, prior to his death.
The coroner issued a prevention of future deaths report, addressed to Justice Secretary Shabana Mahmood and prisons minister James Timpson.
He said on 25 October 2022 – two days before Sleaford died – the inmate was prescribed medication for ankle pain and difficulty sleeping.
Concerns were raised the same day that he had been “under the influence of an illicit substance”, and he was subsequently found with illicitly-brewed alcohol and an “improvised smoking device” in his cell.
As a result, he was downgraded from “enhanced to basic level” prisoner status, which meant his privileges inside the institution – such as the type of job he was permitted to do – would be limited.
Sleaford “did not react well” to the news and told the officer that he would “show [him] basic behaviour”, the report said.
The inquest, at Leicester Coroner’s Court, heard evidence from a prison officer that Sleaford “appeared to be in a good mood” on the night of 26 October.
But he was found unresponsive the following morning.
At 05:45 BST on that morning, the prison officer could not see Sleaford through the cell door’s observation panel because it was obscured from the inside.
However, the officer said she received verbal acknowledgement from him.
Later that day, another officer did not get a response from Sleaford and sought advice from a colleague before they entered to find him unresponsive.
Prison staff then “waited several minutes” while further staff, including prison healthcare workers, attended, followed later by paramedics.
Sleaford could not be revived and was pronounced dead at 08:01, the coroner said.
‘Obvious and crucial gaps’
The report said senior management of the prison had given “clear instruction to officers” that blocking observation panels was not allowed and should be challenged.
However, these rules were flouted with officers allowing the windows to be obscured without sanction, it added.
“This means that a situation prevailed whereby prison officers were unable to routinely see into all cells to check prisoner welfare, but were/are reliant on, and accepted, a verbal response only, which is and remains a significant concern,” Mr Cartwright said.
The coroner also highlighted a lack of “basic lifesaving skills” among prison officers. Some officers did not have CPR training.
He added there were “obvious and crucial gaps” in the response to emergencies at the prison, and that there was “no adequate, clear understanding” or guidance on when an officer should enter a cell when it was believed a prisoner needed immediate care.
The inquest also heard prison officers would “never” enter a cell if they were alone due to fears for their safety.
The coroner said he heard evidence that after April 2024, basic first aid training had been omitted from foundation training for those training to be prison officers, which he said “would probably lead to future deaths in prison custody”.
The justice secretary and prisons minister have until 9 December to respond to the coroner’s report.
A Ministry of Justice spokesperson said: “We will respond to the prevention of future deaths report in due course.”
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