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A prisoner died after staff failed to record his mental health needs, an inquest has found.
A coroner has written to the government concerning the death of Lee Thrumble, who passed away at Medway Maritime Hospital in Gillingham, a day after he was found hanging in his cell at HMP Rochester.
A jury at an inquest into the 26-year-old's death, concluded Mr Thrumble from Broadstairs, died after there were failures to meet his mental health needs and address his deteriorating behaviour.
The inquest recorded how before he was sent to HMP Rochester, Mr Thrumble had been a prisoner at HMP Elmley in Eastchurch, during which he was under the care of the prison's mental health team.
This was not recorded on the relevant information systems, and when Mr Thrumble was transferred to Rochester, he was not provided with mental health support and did not receive a health screening within a day of arriving.
The jury noted how a lack of training among prison staff contributed to failings amounting to information not being recorded properly.
They also heard how leading up to his death, which happened in April 2018, Mr Thrumble's behaviour changed, with him refusing to work, distancing himself from others and appearing quiter.
His medical cause of death was listed as the following: hypoxic brain injury and pneumonia, cardiac arrest, and partial suspension.
Three members of staff from the prison presented evidence which said whilst all prison staff were trained on an information system called National Offender Management Information System (NOMIS), only some clinical staff including nurses were able to access it.
Assistant coroner for Mid Kent and Medway Scott Matthewson wrote to Sajid Javid MP, the health secretary, this month, outlining his concerns surrounding the death.
Mr Matthewson advocated for compulsory training on how to use NOMIS for health staff working in prisons in England and Wales.
The letter was also sent to Mr Thrumble's family, the two prisons, and the chief coroner.
The inquest was held over several days at Shepway Centre, Oxford Road, Maidstone.
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