Jury conclude that prison service failures contributed to prisoner’s death

We were instructed to represent the mother of a prisoner who died after being found suspended from a noose in his prison cell on 5 February 2018.

Solomon Bygrave had fashioned a ligature from a bedsheet. However, earlier in the day, he had handed another ligature to prison staff and was meant to have been checked four times an hour by staff.

Mr Bygrave’s inquest was heard by the Area Coroner for Norfolk, Yvonne Blake sitting with a jury, which concluded that Mr Bygrave had not intended to kill himself when he applied the ligature and returned a conclusion of death by misadventure.

The inquest heard that Mr Bygrave was not checked four times an hour and the bedsheet which he had torn and turned into a ligature earlier in the day was not removed from his cell. Mr Bygrave applied a further ligature and could not be revived despite the attendance of medical staff.

The jury concluded that the failure to complete checks on Mr Bygrave contributed to his death and that staff were not adequately briefed about the risk of Mr Bygrave self harming, which the jury also concluded contributed to Mr Bygrave’s death, together with a failure to complete properly an ACCT document.

Following the inquest, Solomon Bygrave’s mother said: “After more than a year of fighting for justice for Solomon, I am relieved by the outcome of the inquest. I always knew that Solomon didn’t mean to take his own life and his actions were a cry for help.

“The jury’s verdict confirms what his family knew all along. He never intended to leave any of us behind. We are all still coming to terms with the loss of Solomon. I want to thank the members of the jury for their time, the evidence and for their conclusion.

“Whilst he had his problems, to me and those who cared for him, Solomon was a gentle giant. He leaves behind a six-year-old daughter, who he cherished and loved dearly. I intend to tell my granddaughter who her father was and what she meant to him.

“Had more been done to look after Solomon, I believe that he would still be with us today. I truly hope that the prison service and the individuals involved can reflect on Solomon’s story. Standards need to be improved and detainees who are struggling need to be supported, looked after and listened to.

“Whilst I think that justice has been done, nothing will ever bring my son back. I hope that lessons can be learned from Solomon’s case so that no other family has to go through this.”

Ian Brownhill of No 5 Chambers was counsel for Mr Bygrave’s mother at the inquest.