An Aylesbury father-of-three found hanging in his prison cell died as a result of neglect, an inquest jury has said.
Murad Hussain, who had a history of mental health problems, was found dead in his cell at HMP Hewell, Redditch, on November 13, 2012.
The 38 year old had been found not guilty by reason of insanity for an offence committed when in the midst of a psychotic episode.
After being given a hospital order on November 2, 2012, he was expected to be taken to Marlborough House in Milton Keynes but, when no beds were available, he was taken to HMP Hewell instead of HMP Birmingham, where he had been undergoing treatment, because instructions were not recorded on his paperwork.
While at HMP Hewell, Mr Hussain was transferred from the healthcare wing to the main part of the prison, apparently due to the decision of a single nurse without any review of his medical notes or a mental health assessment.
A week later he was found dead.
His mother, Anne Hussain, said: “No mother should ever have to bury her son, and certainly not in circumstances like these.
“I hope lessons will be learned.
“I would like to thank the jury and the coroner for the obvious care with which they investigated Murad’s death, as the jury has found, he was not properly discharged from healthcare, which is where I think he should have remained.
“My son was ill, and he needed treatment.”
During a seven-day inquest, the jury at Worcestershire Coroners Court heard that when he was instead taken to HMP Hewell and placed in the main part of the prison, Mr Hussain received no psychiatric medical care or attention from the mental health team.
This was despite his requests for help and concerns about his behaviour raised by staff and prisoners.
The jury found there were failings by the prison service and Worcestershire Health and Care NHS Trust, with particular criticism of the health body.
Cormac McDonough, Mr Hussain’s family’s solicitor, said he hoped ‘lessons will be learned’ from the ‘tragedy’.
Mr McDonough said: “The jury has found numerous failings on the part of staff and management of HMP Hewell healthcare unit concerning their care of Murad, which at the very least, amounted to missed opportunities to save his life.
“Had an adequate system for the assessment and care of prisoners with mental health problems been in place in November 2012, then the outcome of this case could have been very different.
“The failings raise serious concerns about the deficient systems and dysfunctional staff culture in existence at HMP Hewell, and more generally about the care of prisoners with mental health problems within the prison system.”
A health trust spokesman acknowledged its failings and said they ‘will continue to take all necessary action to reduce the risk of failings in the future’.
The spokesman said: “We offer our condolences to Mr Hussain’s family and we fully accept the coroner’s findings in relation to this case.
“We have already conducted an internal investigation to understand where and how the service offered to Mr Hussain fell below what’s acceptable, and a number of changes have been made to our policies, staffing and procedures.”
The prison service refused to comment.