A failure to take responsibility for the care planning process around prisoners identified as being at risk of suicide or self-harm helped lead to the death of a Chelmsford jail inmate, a report has concluded.

A prison ombudsman report follows the inquest into the death of HMP Chelmsford inmate Daniel Weighman which concluded it was probable that several failings of healthcare and prison staff contributed to his death on January 6, 2023.

This is the ninth self-inflicted death at HMP Chelmsford since 2020, leading to widespread criticism of the prison and its treatment of inmates who are suffering with their mental health.

The jury delivered a narrative verdict, highlighting that it was probable that several failings, including the failure of Castle Rock Group healthcare staff to assess Daniel's risks of self-harm or suicide.

It also highlighted the lack of adequate understanding of healthcare staff and prison officers about their duties under the Assessment, Care in Custody and Teamwork (ACCT) process – the care planning process for prisoners identified as being at risk of suicide or self-harm.

There was also a failure in appropriate ACCT training for healthcare and prison staff at all levels.

That was mirrored in the ombudsman's report which concluded there was "no record of a defensible decision to explain why ACCT procedures were not started and the decision-making was poor and confused".

Daniel who was on remand at HMP Chelmsford at the time of his death had a history of psychotic symptoauditory hallucinations, for which he had received treatment when previously held at HMP Chelmsford.

He also had a history of alcohol misuse. However, he was not placed under the care of the mental health team and was never referred to the team during his initial screening.

An email sent to the head of the mental health department a few days after his induction to the prison, seeking a review of his mental health, was overlooked and Daniel was not reviewed by the mental health team at any point following his arrival to the prison in October 2022.

On 15 October 2022, Mr Daniel Weighman who had a history of mental health issues and self harm appeared settled and prison staff allowed him to see his brother, who was also at the prison.

However, in December 2022, Daniel's behaviour in prison started to change. He became increasingly agitated, which was noticed by friends, family, and the prison officers, and this led to one of his cellmates asking to be moved.

On January 1, 2023, Daniel reported to officers that he would self-harm unless he was seen by a healthcare professional. Daniel was able to speak with a paramedic, where he again expressed his intention to self-harm. Following these conversations neither the prison officer nor the paramedic took any steps to open an ACCT support plan. Daniel's threats of self-harm were initially dismissed as a manipulative attempt to be transferred to the mental health unit.

On 3rd January 2023, Daniel reported to officers that he was "hearing voices" and asked to be moved to the healthcare unit.

A Senior Officer then made a referral to the head of mental health at the prison.

However, again this email was never picked up. Daniel persistently rang his cell bell throughout the day, asking when he would be moved to the healthcare unit. There were no steps taken to ensure Daniel was unable to harm himself whilst in his current cell, and later that day, he was seen with self-harm injuries.

Following this incident, an ACCT was opened, and Daniel was placed on hourly observation, the lowest level of support permissible when an ACCT is opened. Two hours later, Daniel was found harmed and was taken to hospital – where he died three days later.

A statement from the Prisons & Probation Ombudsman said: "When Mr Weighman threatened to harm himself on 1 January, an ACCT was not opened as it should have been.

"Staff accounts differ about why not, and no one took responsibility for starting ACCT procedures, instead passing the accountability to someone other than themselves.

"There is no record of a defensible decision to explain why ACCT procedures were not started and the decision-making was poor and confused.

"Staff missed an opportunity to identify through the ACCT assessment and multidisciplinary review whether Mr Weighman's risk had increased."

It added: "During the investigation, it became apparent that healthcare staff were not adequately trained in ACCT procedures. The Head of Healthcare said that she struggled to get ACCT training for healthcare staff and healthcare staff had been pulled from ACCT training to allow officers to attend."

Chloe Weighman, Daniel's sister, said: "Danny, at his core, was a kind and loving person, and while he made a few mistakes in his life, he never deserved this. HMP Chelmsford has taken Danny from us. If Danny was given the support he so desperately asked for, we would not be where we are today.

"He was repeatedly failed by the prison and healthcare service, who failed to carry out their basic responsibilities towards him, and we have paid the ultimate price for those failures."

Gimhani Eriyagolla, the solicitor from Hodge, Jones & Allen representing Daniel's siblings said the family were "unsurprised by these continued failures of HMP Chelmsford and CRG".

She added: "Too many people have now died because of their careless and slapdash approach to the well-being and health of the men they are charged with looking after.

"If nothing else, we hope that Daniel's case goes on to raise national awareness of the need for our prisons to make sure more lives aren't needlessly lost through easily avoided errors.

"Urgent action is needed to improve and expand the mental health services within our prison system. We need to make sure those in our prison system receive the crucial support they desperately need and are entitled to."

A spokesman for CRG Medical Services said: "We would like to extend our sincere condolences to Mr Weighman's family on the death of their loved one.

"Since Mr Weighman's death, we have made a number of changes to our service to ensure that all patients are receiving high-quality, equitable and timely care.

"We will of course now review the Ombudsman's report and work collaboratively with the prison management team to supply any further information required."