Inquest finds neglect contributed to the death of a vulnerable young man at HMP Bristol

When Georgie arrived at HMP Bristol on 21 September 2023, staff were made aware that he had a history of self-harm. During his time there, he made a number of further attempts to self-harm. Following a ligature attempt on 1 January 2024, he was assessed under the Assessment, Care in Custody and Teamwork (ACCT) procedure. This is a care-planning process used within prisons to identify, monitor and support people at risk of suicide or self-harm.

Despite the known risks, no decision was made to place Georgie under constant observation or to remove items that could be used for self-harm.

Responsibility for Georgie’s care was shared between HMP Bristol and Oxleas Healthcare NHS Foundation Trust. HMP Bristol was responsible for his day-to-day custodial care, including responding to concerns about self-harm and managing his risk under the ACCT procedure. Oxleas Healthcare NHS Foundation Trust provided healthcare services within the prison, including mental healthcare, and was involved in assessing and managing Georgie’s mental health needs and risks.

Georgie had been specifically told to use his emergency cell bell if he felt unsafe. In the early hours of 2 January 2024, he pressed his cell bell, but it went unanswered for nearly 15 minutes. CCTV footage showed that the individual responsible for that wing was watching television on a computer during that time and ignored the call.

When the individual eventually attended Georgie’s cell, he was found unconscious after using a ligature and a ‘code blue’ prison alert was raised. Healthcare staff were delayed in reaching the scene because of confusion about which prison officer should meet and escort them there.

The 10 day inquest took place before HM Senior Coroner Maria Voisin at Avon Coroner’s Court in Bristol between 1 and 12 June 2026. The jury heard oral evidence from 27 witnesses and considered the events leading up to Georgie’s death.

The evidence heard raised concerns about the assessment of Georgie’s risk on 1 January 2024. Although the staff member carrying out the ACCT assessment acknowledged that Georgie’s level of risk was escalating, including more frequent cell bell use and attempts of self-harm, he did not consider it necessary to speak to healthcare staff or to the prison officer who had found Georgie in his cell before assessing his risk.

The jury also heard evidence that the individual responsible for Georgie’s wing said staff were allowed to watch television during the night shift because they were not given breaks.

The jury found that Georgie’s death was contributed to by neglect. In particular, it identified the following issues:

• The failure to respond to the emergency cell bell caused a significant delay in Georgie receiving life-saving care;
• Unsatisfactory processes and prison protocols in force at the time of his death;
• Inadequate communication and information sharing between prison and healthcare staff;
• Inconsistencies in shift handovers, contributed to by a lack of awareness of his risk.

Georgie’s family said: “We are grateful that the jury took time to carefully consider the events leading up to Georgie’s death whilst at HMP Bristol.

The jury’s conclusion confirms our worst fears about the care that was provided to Georgie, during what was a very vulnerable time for him. Whilst we are glad that their conclusion recognises the appalling failings in care, it is utterly heartbreaking to know that his death was entirely avoidable. We miss him every day and always will.”

Georgie’s case highlights the importance of prisons and healthcare providers working together to identify and respond to escalating risks of self-harm. It also demonstrates how delays in responding to emergency cell bells, failures in communication and inadequate handover processes can have devastating consequences for vulnerable people in custody.

Miryam Vermaat of RWK Goodman, who is representing the family, said: “Georgie was a vulnerable young man, and this was well known to those responsible for his care whilst at HMP Bristol. Despite the fact he was clearly deteriorating, Georgie did not receive the basic support that would likely have altered the course of events.

We welcome the changes that have since been implemented at HMP Bristol and Oxleas Healthcare NHS Foundation Trust, but for Georgie and his family those changes have come too late. We sincerely hope that all those involved learn the necessary lessons so that this does not happen again.”

We are supporting Georgie’s family with their claim against the Ministry of Justice and Oxleas NHS Foundation Trust for the failures leading to his untimely death.

Georgie’s family are represented by Miryam Vermaat of RWK Goodman and Beatrice Baskett of St John’s Chambers. If you would like to speak to our team about an inquest, or about seeking answers following the death of a loved one, please contact Miryam Vermaat at [email protected].