On 29th January 2015 I commenced an investigation into the death of Lee Stewart RUSHTON, Aged 24. The investigation concluded at the end of the inquest on 9th-13th May and 16th -19th May 2016. The cause of death was: 1a Hanging

The Jury concluded: Lee Rushton died from an Accidental death contributed to by neglect. Mr Rushton was in a dependant position due to mental illness and incarceration. There was a failure to provide and procure basic medical attention. Lee not being discussed at the Single point referral was a gross Failure. The failure to provide medical attention to meet his needs could have saved or prolonged his life. Findings which more than minimally, trivially or negligibly contributed to his death  Failure for single point Assessment  The lack of consistent and sufficient mental health assessment  Assumption of others  Vulnerable prisoner in a single cell  Failure to take action based on observation in ACCT  The lack of understanding or sufficient explanation for Lee about P.P.U.  Inability to send a message.

Lee Stewart Rushton died at 14.12 pm on the 28th January 2015 in Cell 13 on the third level of I wing at HMP Liverpool. This was his first time in prison having arrived on the evening of the 22nd January 2015. He was found hanging from a ligature fashioned from a blanket. The Jury found, “We find it is more likely than not the case Lee Stewart Rushton put himself in the position in which he was found but that he did not intend to end his life. Due to not receiving adequate mental health care and a number of missed opportunities we are unable to determine whether Lee acted with intent and of his own free will. A real and imminent risk of self-harm or suicide was recognised on his reception into the prison by the opening of an ACCT. however the risk was not managed adequately and effectively during Lee's time under their care. The ways in which we deem this risk to be inadequate and ineffective managed are;  Failure for Lee to be discussed at the single point assessment meeting despite being referred on 2 separate occasions.  Failure to recognise Lee's level of vulnerability during first case review as a part of the ACCT process.  Failure to fully explain the P.P.U. system to Lee properly which removed a major protective factor.  Ineffective use of cell share assessment leading to a vulnerable adult being left alone at a higher risk of self-harm/suicide.  Distinct lack of communication which resulted in Lee's mental health care not being addressed.  The procedures under the ACCT system were not followed or managed appropriately.  Missed opportunities to increase observations on multiple occasions.  Multidisciplinary approach to the ACCT failed. Ambiguity over who is responsible for actions within the ACCT.  Distinct lack of ownership of issues arising from the ACCT.  Numerous flash points when an ACCT review could have been called but were missed.  Incorrect completion of forms where actions were noted as complete but were not, i.e. Care map.  Failure to record actions on ACCT.  Significant observations and issues recalled on testimony not logged within the ACCT. Mr Rushton's drug dependency presentation was recognised initially, however the management was inadequate.  Missed methadone treatments.  Difference between medical opinions resulting in different withdrawal treatments on different occasions.  Lack of recording for medical decisions made. As a result of lack of continuity of treatment for drug dependency added stress or anxiety that more likely than not contributed to his intentions concerning self-harm or not. There was not an adequate or effective assessment of Mr Rushton's mental health in addition to drug dependency presentation. The effect of drug dependency on Lee's mental health was not addressed sufficiently. On 23rd January 2015 injuries sustained by Lee Rushton on H Wing were not appropriately investigated.  No evidence available in regards to investigation of the situation.  On the balance of probability it is more likely than not the incident added to Lee's vulnerability given his mental state.  Expressed feelings of fear documented in C.NOMIS