A CORONER has slammed ‘serious failings’ which allowed a man labelled a ‘very high’ suicide risk to kill himself within 20 hours of being jailed.

Dr James Adeley is to write to the Ministry of Justice calling for urgent national action after Blackburn plasterer Kieron Gray used a razor blade to end his life at HMP Preston following a ‘catalogue of errors’.

His father Sean said ‘mistake after mistake’ was made after Mr Gray was sentenced to two years in prison for arson. He had always maintained he was innocent of setting a fire at his ex-partner’s flat.

In a damning statement read out at the end of the three weeks-long inquest at Preston Coroner’s Court, coroner Dr Adeley said:

  • Probation staff did not inform court custody staff Mr Gray was a ‘very high suicide risk’;
  • A pre-sentence report stating Mr Gray was a high risk and given to court custody staff in a sealed brown envelope was not opened by prison staff.
  • A risk of self harm form was faxed to the prison late. When it arrived, only the front page of the document was found on a desk.
  • The officer who found the document made no effort to locate Mr Gray or notify staff responsible for him.

The inquest heard Mr Gray, 42, suffered a stroke and was left wheelchair-bound soon after being accused of setting the fire in January, 2010.

He had been undergoing rehabilitation and, with support from his family, had made good progress in his recovery, the inquest was told.

However, in June, 2011, he was convicted of arson with reckless endangerment to life and two months later was told he was being sent to prison.

Summing up the case, Dr Adeley said: “Some 20 hours after entering custody, he requested a disposable razor to go to the shower with as he was unable to shave in his cell due to the height of the mirror.

“A short while later he was found on the floor of the shower with four deep lacerations to his body over areas associated with major blood vessels.”

A jury recorded that Mr Gray took his own life, but Dr Adeley said the death could have been avoided if communications had been better.

The coroner for North Lancashire and Preston said he would be writing to probation and prison services across England and Wales to highlight the failings which he believed were not limited to Preston Prison.

Dr Adeley said: “Detailed information warning of an immediate risk of suicide was within the possession of the prison staff for a full 20 hours before he mortally wounded himself and no-one in the prison was even aware of this warning of possible imminent disaster.

“All of the mechanisms that should have ensured the information was transmitted to court custody staff and the prison was either absent, late of ineffectual due to internal failures of discipline and healthcare staff within the prison.

“Furthermore, the information sent to the prison in the reports with Kieron Gray was ignored at all material times.

“While it cannot be said if such knowledge had been used to inform questioning and obtain a full assessment of his risk he would not have died at the time he did, the failure of timely delivery, failure to act upon warnings sent and lack of appreciation of information warning of an immediate risk was a very serious failing in the state’s safe detention practices of prisoners.”

Kelly Darlington, of Farley’s Solicitors, who represented the family, said: “The inquest into the death of Kieron Gray highlighted a catalogue of errors in the way information is communicated and managed between organisations involved in sentencing an offender to prison.

“The coroner made a number of welcomed recommendations aimed at a national level and called for an urgent review of systems and procedures in place between the probation and prison service in England and Wales.

“These recommendations aim to ensure that custody is a safer place for prisoners who pose a high risk of self harm.”

Mr Gray’s father Sean, of Preston New Road, said: “I miss Kieron terribly. I used to see him every day.

“We have been through a real ordeal as we have been dealing with his death now for two years.

“When they jailed him I said then they had given him the death sentence.

“After that it was just one mistake after another.

“It was good to finally get some closure and hopefully, with the coroner saying what he has, other people’s lives could be saved.”

Mr Gray also left behind a brother, Dermot, and two daughters Michaela, 22, and Laura, 20.