Investigation into the circumstances surrounding the death of a man at HMP Liverpool in November 2006 — (Prisons and Probation Ombudsman)

SSRI Ed note: Man on citalopram becomes suicidal, expresses suicidal thoughts to staff, later hangs himself.

To view complete transcript of inquest click here

Report by the Prisons and Probation Ombudsman for England and Wales

in November 2006


The man was remanded to HMP Forest Bank on 24 June 2006 from the Magistrates’ Court. As a drug user, he was offered a detoxification regime.  However, he refused this preferring to ‘detox’ himself using illicit Subutex.

The man was not happy to be at Forest Bank, possibly because of a conflict with a local drug gang. He spent much of his time at Forest Bank away from normal location, either because he asked for protection or due to breaches of prison discipline. After a Crown Court appearance in September, the man was re-allocated to HMP Liverpool.

He had been prescribed Citalopram, an anti-depressant medication, at Forest Bank and this was continued at Liverpool, along with Tramadol for pain relief. Over time, the Citalopram dosage was increased while the Tramadol was reduced.

The man ran up a drug debt, and was concerned for his own safety as he was unable to repay it. He asked for Vulnerable Prisoner (VP) status for his own protection on 18 October. He remained off the normal wings until 22 November when he said he was happy and that the threat had passed.

While the man had not previously expressed any direct intention to self-harm, on 15 November he told a nurse that the previous week he had been feeling low and had made a noose which he had hung from the bars of his window. On 21 November, he made a threat to throw himself off the five’s landing if he was not taken off the VP wing.

About 11.40 am on 29 November 2006, the man’s cell mate returned from education and saw him hanging from the window bars of their shared cell, B4-10. Officers immediately entered the cell, cut him down and started attempts at resuscitation. Despite their efforts, and those of the paramedics and a doctor who arrived a short while later, the man was pronounced dead at 12.00 noon.

An inquest into the man’s death was held in October 2009, the verdict of which was death by misadventure.