An inquest into the death of an inmate found that prison staff falsified monitoring records in the hours leading up to his suicide. The deceased, identified as Mr. Osborne, was under ACCT (Assessment, Care in Custody and Teamwork) monitoring, which mandates checks on vulnerable prisoners at least every 20 minutes. However, on November 25, there were no recorded observations between 2:32 p.m. and 4:22 p.m., a period during which he took his own life.

The inquest revealed that staff assigned to supervise Mr. Osborne, who was held in segregation, were distracted by television coverage of football reporting instead of conducting proper checks. Furthermore, the coroner criticized the conditions of Mr. Osborne’s cell, highlighting it did not meet basic standards, including the absence of a mattress.

According to prison regulations, inmates should not be subjected to solitary confinement defined as being confined alone for 22 hours or more per day without human contact. However, evidence presented during the hearing indicated that Mr. Osborne’s cell door was opened for less than three minutes in the three days preceding his death.

Adrian Usher, Prisons and Probation Ombudsman, emphasized that segregation of prisoners on ACCT monitoring should only occur under exceptional circumstances, underscoring concerns about appropriate care and supervision in such cases. The coroner issued a prevention of future deaths report, calling attention to failures in oversight and accommodation standards that may have contributed to the tragedy.