A schizophrenic man’s death could have been prevented had he been sectioned in hospital rather than being sent to prison where he ended his life just days after being arrested.
Gareth Frew was on remand at Exeter Prison where many opportunities to provide him with the right mental health care were missed, a jury inquest heard.
The 48-year-old was found hanging in his cell on October 18, 2017.
A number of changes have since been made at the prison following his death. At the time he was in custody Exeter Prison more than 60 per cent of prison officers were newly recruited, there was staffing shortages and reports of bullying, drugs and fighting were commonplace.
Dr Maganty, who gave evidence as an expert, told the inquest that as Mr Frew had been made the subject of a Community Treatment Order (CTO) due to his mental health before his detention at Exeter Prison, he should not have been in prison, but instead to a medium secure psychiatric unit.
He added safeguarding processes at Exeter Prison for someone who was severely mentally ill had been ‘seriously deficient’, and on balance his death ‘could have been avoided’.
The jury returned a conclusion of suicide and said what probably contributed to his death was a failure to enforce his CTO, and insufficient communication between health staff, discipline staff and Mr Frew.
Medical reports confirmed Mr Frew, of Cornwall, had a history of drug dependency and schizophrenia dating back to his early 20s. It resulted it psychiatric admissions, self-harm and a past suicide attempt.
His daughter talked of periods of remission when he was ‘kind and gentle’, and that when he was unwell it was ‘unbelievable’ when compared with the man she knew.
In April 2017, he was restrained from jumping off the Tamar Bridge and was detained on a psychiatric ward. The jury heard it related to concerns about a forthcoming mental health tribunal.
Two months later he took an intentional overdose in response to his diazepam prescription being stopped.
In August 2017, he damaged a number of windows and car windscreens at Trevillis House, a community base for a number of staff providing mental health and dementia services in Cornwall.
He later contacted the police informing them what he had done and told a psychiatrist that the only reason why he did not set fire to the building was because he could not afford to buy petrol.
Mr Frew said it was in response to being put on a CTO against his will. He was willingly admitted to a psychiatric ward at Bodmin Hospital, but discharged himself two days later, and was not deemed sectionable at that time.
In October 2017 he was charged with arson with intent to endanger life after setting fire to his flat in Liskeard.
Two people were rescued from the building, above Bradleys Estate Agents on Bay Tree Hill, at about 6.20am on October 13.
It was heard Mr Frew was angry that he was being pursued for money owed by the previous tenant, and he had disconnected the smoke detectors because he thought that they were fitted with cameras and were costing him £10 a week.
Consultant psychiatrist Dr Laugharne, who had known Mr Frew for 16 years, told the inquest Mr Frew had capacity and that he should bear the consequences of his actions.
His view was that it was appropriate for Mr Frew to be processed through the criminal justice route.
Dr Laugharne said that he ‘felt guilty’ of the outcome of Mr Frew and was desperately sad at what happened, but faced with the same circumstances again he would not have acted any differently.
The jury heard that when Mr Frew was arrested on October 13, he was taken to the Charles Cross Police Custody facility where it was recognised that he was mentally ill.
He was charged with three offences. Bail was refused and he was sent to Truro Magistrates Court the next day and remanded in custody to Exeter Prison where it was noted he was acting strangely.
Mr Frew complained he should not be in prison because he was the subject of a CTO, and said that he wanted to die.
An officer told how she did not take it seriously but decided to open an Assessment, Care in Custody and Teamwork (ACCT) – the care planning process for prisoners identified as being at risk of suicide or self-harm – to be on the safe side.
It was heard how Mr Frew’s presentation continued to fluctuate, and that not all requirements of being under an ACCT were carried out in the correct timeframe or by those with the right mental health training. Some staff also did not have access to his previous history records.
It was added that on one day the prison was short staffed with five officers having to deal with 180 prisoners.
A prison officer described the wing Mr Frew was on as being noisy, and not the ideal atmosphere for someone with mental health problems.
He added Exeter Prison is a lot more ‘confrontational’ and with more drugs available than at other prisons, and there were fights most days.
During Mr Frew’s short stay in prison, the jury heard there were concerns he was not taking his medication, had stopped engaging, was blockading his door and covering the observation panel of his cell door, and was hearing voices.
It was added that on the day he died, Mr Frew had been robbed of his nicotine patches and had been reluctant to come out of his cell for fear of being beaten up.
He was found hanging in his cell around 7.20pm on October 18, by an officer carrying out cell checks.
Dr Brown, a forensic psychiatrist who worked at the prison, said a transfer to Langdon Hospital, a semi secure psychiatric hospital, was going to be the likely outcome for Mr Frew.
She agreed that it would have been helpful for Mr Frew to have been told of the intention to transfer him to a psychiatric hospital because it would have given him some hope.
The jury heard that following Mr Frew’s death, a number of changes have been made at the prison. These include only qualified ACCT case managers are now permitted to carry out reviews, and in almost 100 per cent of cases, there is a mental health professional present at the first ACCT review.
It was added that a project is shortly to be undertaken to renew the windows at the prison so that bars are not accessible as ligature points.