A father-of-four was found dead in his cell at HMP Peterborough having taken his own life after a catalogue of mistakes and neglect by jail staff, an inquest heard.
Sean McCann (32), who had a history of mental ill health, had tried to take his own life twice before and repeatedly said he wanted to kill himself in the weeks before his death.
Despite this he was placed in a cell at the prison privately run by Sodexo where he was able to carry out his suicide before being found by staff on March 13, 2016.
The inquest heard that staff had failed to properly assess his mental health, were not sufficiently trained and had failed to rid the cell of objects which could have been used for the suicide.
It also heard that there was a delay in entering Mr McCann’s cell which contributed to his death. The jury ruled that his death was an accident contributed to by neglect.
Following the two week inquest at the coroner’s court, Mr McCann’s family said: “This verdict won’t bring Sean back, but we hope that some good can come from his death.
“We hope that Peterborough prison will learn from their mistakes and make urgent changes to how the prison is run so that more lives aren’t wasted and other families can be spared the pain we have been through.
“Despite Sean’s difficulties in life he was a loving son, brother and father. He was the life and soul of our family and we miss him dearly.”
Cormac McDonough, a specialist civil liberties solicitor from Hodge Jones & Allen, who represented the family, said: “The jury have delivered a truly damning verdict which criticises almost every aspect of the care that staff at Peterborough provided to Sean.”
The family were represented at the inquest by Stephen Simblet of Garden Court Chambers.
Mr McCann, who was from Aylesbury, Buckinghamshire, was jailed for two years for assault and other offences in August 2015, according to the solicitors who represented him. He was moved from HMP Chelmsford to HMP Peterborough in January 2016.
On February 4, 2016, he failed to attend a scheduled mental health appointment and on February 29 and March 10 he attempted to take his own life.
On the afternoon of March 13 Sean informed staff several times that he wanted to kill himself.
On the same day an officer spotted something abnormal in cell 2 of the segregation unit but failed to tell other staff or to take steps to put the cell out of use.
Sean was moved into this cell and the last time he was seen alive was 6.25pm. He did not respond to officers when they attempted to communicate with him. No alarm was raised by officers in response to this.
At 7.06pm officers entered his cell and found him dead.
A spokesperson for HMP Peterborough said: “The safety and wellbeing of those in our care is always our priority. However, we acknowledge that mistakes were made in the care of Mr McCann and our thoughts continue to be with his family and friends.
“Since his death in 2016 we have strengthened our procedures and will use the recommendations from the inquest to make further improvements to ensure our systems are more robust.”