Almost 10 prisoners a month kill themselves in UK jails, with much of the blame placed on neglect and costcutting. That is what led to the death of Dean Saunders, according to his family – and a jury has agreed

About two weeks before Dean Saunders killed himself in his prison cell, a manager from the private company running healthcare in the prison was heard to express concerns about the cost of keeping prisoners under constant suicide watch, according to evidence presented at his inquest. Monitoring of Saunders’s cell was subsequently reduced. On 4 January 2016, in between the checks made on his cell, he succeeded in taking his own life. An inquest into his death last week concluded that “financial consideration” had played a “significant” part in the decision to reduce the level of observations.

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But so many other things went wrong during the 18 days Saunders was in prison that this catastrophic decision was just one of many that led to the death of a seriously ill young father who had never previously been to jail, and should not have been in prison. The jury found neglect contributed to his death.

Last year, a record number of prisoners committed suicide in jails in England and Wales, with at least 113 recorded, nearly 10 a month (the number may prove higher still when the Ministry of Justice releases the final figures on Thursday). Campaigners for prison reform see this as the inevitable consequence of the overcrowded, underfunded and understaffed prison system. Despite a multitude of damning inquest verdicts, excoriating prison inspection reports and thoughtful reviews into what should be done, there has been no concerted action to address the issue.

“There’s no political will. Dead prisoners do not win votes,” Deborah Coles, the director of the deaths in custody campaign group Inquest, says wearily, acknowledging that she is angry at the soaring numbers and exhausted by the lack of progress.

But Saunders’ parents, Donna and Mark, and his partner Clare Hobday-Saunders have a stubborn determination to pull something constructive out his death. Still shaken by the findings of the inquest last Friday, they are nevertheless preparing for a meeting with the prisons minister Sam Gyimah to confront him with the case for change. Meanwhile, they have rallied themselves to talk in detail about the ways in which Dean was failed. Clare has taken holiday from her job at a phone shop, and Donna and Mark, both bus drivers, are also on leave this week so that they can try to get attention focused on what happened to Dean, who was 25 when he died.

As they explain what happened, it becomes clear that his story charts the tragic collision of two national crises: one in the mental health system and a second in the prison system.

“I know I am just a nobody, but I feel responsible,” Mark Saunders says at Clare’s flat in Basildon, Essex, in a conversation punctuated by the happy babble of Clare and Dean’s two-year-old son, who is serving his grandparents wooden bits of food, cooked in his toy oven. “There is a culture that what happens in those prison walls stays in those walls. The only way we can change it, is if we get people to look in and understand what is happening.”

Facebook Twitter Pinterest Dean, Clare and their baby son. Photograph: Graeme Robertson/The Guardian

Until December 2015, Dean’s life was fairly unremarkable. He had a stable, happy family set-up, and was the main carer for his baby son, while Clare went to work. All the family photos show the two of them together; Clare says they were inseparable. But in December, he had an unexpected and unexplained serious mental health crisis, and went home to his parents for a couple of days. While he was there his behaviour became increasingly paranoid. Suddenly convinced his family had turned against him, he picked up a bread knife and tried to cut his brother’s throat. Luckily, the injuries were relatively minor.

His father wrestled the knife out of his son’s hand. In the fracas that followed, Dean picked up a second knife from the kitchen table and attempted to cut his own throat. As Mark tried to prevent his son from harming himself, he was stabbed in the stomach with the knife. Moments later, Dean asked his father why he was holding him down. “He said: ‘Dad, I’d never hurt you. I love you.’ It was as if he wasn’t aware of what had happened,” Mark says. He had never been violent before.

The police were called, and charged Dean with two counts of attempted murder, but assured his family that they understood he was very unwell, and that he would be transferred to a hospital. However, there was no bed at the appropriate secure hospital, and instead he was taken to Chelmsford prison. The family had no desire to press charges, and they were promised repeatedly by the police that he would be safe and well looked after.

Everyone acknowledges now that Saunders should not have been sent to prison; it was a temporary measure because there was no hospital bed. He had told his family that he was going to kill himself; notes were sent explaining to prison staff that he was a high suicide risk, and that he should be under constant observation.

The prisons and probation ombudsman review into his death notes that staff were concerned about his paranoid behaviour: he thought the staff had microphones in their hair and cameras in their glasses. He put a plastic bag over his head in his cell, and threatened to pour a kettle of boiling water on to his head. Later, he wanted to see the chaplain to discuss his funeral plans; he talked about wanting a lethal injection to speed things up.

First thing on the Monday morning after his admission to prison, staff held an ACCT (assessment, care in custody and teamwork) meeting, to determine how he would be looked after. There was no progress on the transfer to hospital. The inquest jury found that the head of healthcare, working for Care UK, the private company that had the contract to run healthcare in the prison, had “to a very large extent predetermined” the decision to reduce monitoring of Dean’s cell before she went into a meeting to assess his needs. The official denied this claim during the hearing as well as the suggestion that she took costs into consideration.



When Clare and Donna visited on 23 December, they were very worried by Dean’s behaviour. He told them that the prison staff were planning to kill him; he said he had seen gas cannisters and a chair where staff were going to perform a live autopsy on him. The meeting was cut short because Dean was very suspicious of them.

They were so worried that they asked to see someone caring for him. They met a mental health nurse, who said they thought they were building up trust. When Donna rang later to check that he was being watched and to reiterate her concerns, she found out that this had been reduced to half-hourly checks. The family called the prison 20 times over the period Dean was in Chelmsford, anxious to find out about his state of mind, and hoping that staff would pass on messages of love and support to him; they are not sure that the messages got through. They were distressed he had not called them, but during the inquest it emerged that he had asked staff repeatedly for their numbers so he could call, and had not been given them.

Facebook Twitter Pinterest HMP Chelmsford. Photograph: Si Barber

When Clare asked for her number to be given to Dean, it was noted down against the wrong prisoner in the logs. “All the time we were told: ‘He is safe, he is secure, don’t worry,’” Clare says. “I don’t think our messages were passed on. We feel horrified that he spent those last days feeling abandoned by those who loved him.”

Over Christmas, there was no progress in the transfer to hospital. The psychiatrist was on holiday. Dean refused to take medication and his condition got worse. On 4 January, a family liaison officer visited Clare at her parents’ home to tell her that Dean had killed himself.

“All the way through, we were treated wrongly and so was he,” she says. “There should be another pathway for people who are mentally unwell. He should have been in hospital, instead he was caged in a Victorian-style prison over Christmas, not able to speak to his family.”

The family has had sorry-for-your-loss-style condolence messages from the prison and from Care UK, but no formal apology – which upsets and surprises them. In statements, the Ministry of Justice and Care UK acknowledge mistakes were made.

“HMP Chelmsford have already put in place a number of measures to better support offenders suffering from mental health problems following the PPO investigation into the death of Mr Saunders, and we will now carefully consider the findings of the inquest,” the Ministry of Justice said in an emailed statement.

They added that £14m had been invested to provide 400 extra staff members in the country’s 10 most challenging prisons, which includes Chelmsford. The MoJ notes that the prison was awarded £164,000 last June, which has gone to pay for a “dedicated safety custody manager” and also for “provision of in-cell activity packs for those at risk of self-harm – mindfulness activities such as puzzles, jigsaws”.

In a statement, Care UK “offers its condolences” and adds that prison was not the right place for Dean Saunders. “It is hugely regrettable that a place in a secure specialist mental hospital was not found when Mr Saunders was at the police station.”

Care UK’s medical director for health in justice, Dr Sarah Bromley, says that any decision on how frequently a prisoner should be observed would have been made collectively between healthcare and prison staff. “The healthcare input to the decisions should not be influenced in any way by financial considerations. It is unacceptable if this is the case. As a result of the inquest’s finding, Care UK is reviewing its processes and policies.”

An Independent Monitoring Board inspection of Chelmsford prison published this month noted that the “level of service being provided to care for prisoners’ physical and mental health needs remains inadequate”. It highlighted Care UK’s difficulties with recruiting and retaining staff and its reliance on agency staff “to cover clinical vacancies”. It also states that across the prison, “government budgetary cuts have continued and reflect a much lower number of officers”. The latest prison inspection also said that healthcare provision at Chelmsford was inadequate and had got worse since the last inspection, exacerbated by staff shortages.

Reading between the lines of the Care UK condolence statement, there is some attempt to shift responsibility back to the Ministry of Justice. The company suggests that it is impossible to provide good healthcare when the prison is understaffed, and goes on to say it has decided to stop working at Chelmsford prison, indicating that it was not possible to do its job properly in an environment where a prison is understaffed. The company will leave Chelmsford in May.

Deborah Coles of Inquest is shocked by clear link between budget pressure and the downgrading of Dean’s suicide watch: “It is absolutely scandalous – this pursuit of profit overriding the duty of care to a vulnerable prisoner. You could not have had a more vulnerable prisoner; everyone had accepted him as one, it was marked clearly on his notes. If you can’t protect someone like him, who can you protect? Sadly this is not an isolated case. Until they radically reduce the prison population this will continue.

Mark says he feels there was a “toxic mix of understaffing, inadequate training, inadequate information, complacency, lack of passing information between all of them”. He feels despondent when he reads accounts of other deaths in Chelmsford prison and elsewhere in the prison estate. “There are clear patterns. If someone died on your watch, surely you would do everything you can to stop it happening again. It is almost as if it is an accepted part of prison life that someone is going to die.”

Clare is still struggling to come to terms with the conclusion that the death was “predictable and preventable”. “If only the people responsible for keeping him safe had simply done their jobs, then Dean would be alive today. He was a very proud dad. Life was just really beginning for him.”

In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14.