Multi-agency failures found in care of sectioned patient 

A jury has found that a 29-year-old man who suffered from mental health problems was let down by the care he received at HMP Woodhill as well as in the care of Oxford Health NHS Foundation Trust.
 
An inquest was held into the death of Jack Portland at Buckinghamshire Coroner’s Court, Beaconsfield, between 23rd January and 3rd February 2017. Jack died on 27 December 2015.
 
The jury concluded on Friday 3 February that there had been a range of failures by the public bodies responsible for keeping Jack safe when in custody and when sectioned under the Mental Health Act in hospital.
 
Popular at school and described by his friends and family as lively and outgoing he had struggled with drug addiction. The jury heard that he had deliberately shoplifted in desperation, in the belief that he could get clean in prison. Instead he was exposed to widespread availability of the drug Spice and developed psychotic symptoms for the first time. His parents' concerns about their son went unanswered.
 
Failings were found by the jury in the discharge and resettlement process at HMP Woodhill. Aftercare is essential for vulnerable prisoners returning to the community. HMP Woodhill has been repeatedly criticised by Coroners and the Prison and Probation Ombudsman for shortcomings in its safety procedures and protection for its most vulnerable prisoners. In 2016 HMP Woodhill recorded the highest number and highest rate of self-inflicted deaths across the entire prison estate.
 
The jury also found four categories of failure at the Whiteleaf Centre where Jack was a patient at the time of his death. They found failings in risk assessment process, communication with Jack's family, leave systems and how they respond to patients absent without leave (awol). 
 
Jack died while on one-hour unescorted community leave and his absence went unnoticed for an hour-and-a-half after he was due to return. The Police were not called for over two hours. His family were never informed he was missing.
 
In a statement released after the verdict the family of Jack Portland said:
 
"The family are grateful for the professional services of the coroner's office and the process they have experienced in the past two weeks, and over the past year in preparation for the inquest of their son, Jack Portland. 
 
"Losing a loved one is very difficult, losing a child in tragic circumstances is a life time sentence in regret; knowing the life experiences we all enjoy have been cut short for him, wishing things were different.  One of the last things Jack 'wrote' was 'life's short, don't be lazy', good advice son and I hope we have done you justice.
 
"We value the opportunity to participate in the inquest process and the resulting findings of the jury.
 
"The culmination of the inquest process and the recognition of Jack as a person, exhibiting and experiencing a constellation of health concerns, demonstrated by the jury’s finding that there were failings in his care, is some relief to us.
 
“However we are saddened that the experience of people with impaired mental health, coupled with addiction, is continuing to be misunderstood, a stigma applied and their care mismanaged.
 
“It’s evident that society still has a long way to go in treating everyone with equal concern. The family will continue to try and effect a positive change for people in need of support and understanding.
 
“The family would like to thank the legal team and inquest.org for all their hard work and support.”
 
The family were represented by Caoilfhionn Gallagher of Doughty Street Chambers and Merry Varney and Benjamin Burrows of Leigh Day, members of the Inquest Lawyers Group.