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Maidstone Prison has revised the way it deals with prisoners considered at risk of self-harm or suicide after the death of an inmate.
Petrut Cristea, a Romanian national serving a seven-year sentence for causing grievous bodily harm, died in Maidstone Hospital on June 4 last year.
He had been taken there a few days before after being discovered suspended in his cell on June 1.
An inquest at the Shepway Centre in Oxford Road, Maidstone, held before a jury of five men and five women, heard that when a prison officer unlocked his cell at around 9.45am, Mr Cristea had been found hanged and unresponsive.
However, efforts initiated by prison staff using a defibrillator and later by Secamb medics had succeeded in restoring a partial circulation and he was taken to hospital attached to a Lucas compression machine to induce artificial breathing, and placed in intensive care.
Sadly, however, the lack of oxygen had caused permanent brain damage and he never regained conciousness.
The jury heard that the 26-year-old had a long history of self-harming during his time at the prison since 2019.
Whenever he did so, the prison would open a process known as Assessment, Care in Custody and Teamwork (ACCT) during which he would be closely observed by prison staff and assisted by a multi-disciplinary team that might include heath-care professionals, psychiatric services and sometimes the prison chaplaincy, as required.
Once a prisoner was considered to be over the crisis and no longer at risk of self-harm or suicide, the ACCT would be closed, but only if all the professionals from the multi-disciplinary team attending a review - and the prisoner himself - agreed.
Mr Cristea had been subject to an ACCT between March 29 and April 29, when it was discovered that one of the reasons for his distress was his feeling of estrangement from his family in Romania. Attempts were made to put him in touch with them.
He was placed on an ACCT again on May 29, after he cut his stomach. This time it was determined that the cause of Mr Cristea's concern was that he believed his cell on Kent Wing to be haunted. Mr Cristea was known to have taken both cannabis and spice while in prison.
He was moved to another cell and he immediately seemed much more cheerful, so the ACCT was closed the next day, May 30, which was just two days before he was found suspended.
Senior prison officer Shane Maybourne told the inquest that closing an ACCT was not the end of the process. The case would be routinely reviewed and in any case Mr Maybourne was carrying out welfare checks daily on every prisoner in his care, because he was aware that the Covid lockdown was placing extra stress on everyone.
"I saw rapid changes in Mr Cristea - but all for the better..."
He explained that the ACCT process was solely for when prisoners were in crisis. He said: "Lots of people in prison suffer from mental health issues. It is a continuous thing. You deal with one issue than later something else comes up."
But following the closure of the ACCT on May 30, he said: "I saw rapid changes in Mr Cristea - but all for the better."
Although, the prison had some anti-suicide cells specifically designed to deny prisoners the opportunity of securing a ligature anywhere, Mr Cristea's cell was not one of them.
That was because he had always denied any intention of taking his own life.
The last person to speak to Mr Cristea was a fellow inmate, Lotto Galo St Thomas, who had the job of sweeping the corridor outside the cells.
He spoke to Mr Cristea through the hatch of his cell door at around 7am. He said that Mr Cristea was angry that he had run out of vape (a cigarette substitute) but otherwise seemed normal. Mr Cristea had said nothing that led Mr St Thomas to think he intended to take his own life.
After three hours of reflection, the jury returned a unanimous verdict that although Mr Cristea had died as a result of his own actions, it was "an act of attention-seeking and self-harm and not suicide."
They said that Mr Cristea "would have benefitted by the ACCT being kept open another 24 hours."
Following the jury's conclusion, the coroner Sonia Hayes said she had considered whether there was any need for her to make a "Rule 43" report to prevent future deaths, but decided there wasn't since counsel acting for HMP Maidstone had already assured her that the prison had now changed its rules, so that once an ACCT had been opened, it would be kept in place for a minimum of 72 hours.
There were no friends or relatives of Mr Cristea at the hearing.
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