HMP Wakefield prisoner, 24, had already died by suicide in cell when officers doing welfare checks thought he was watching TV
A coroner has raised concerns after an inquest heard a 24-year-old inmate at HMP Wakefield had already taken his own life in his locked cell when prison officers doing welfare checks noted that he appeared to be watching television.
Connor Hoult died by suicide at the maximum security prison on June 10 2019, an inquest at Wakefield Coroner's Court found.
Assistant Coroner Janine Wolstenholme has issued a prevention of future deaths report amid concerns that prison officers are not getting a response from prisoners during welfare checks and are not being told to do so.
The report has been sent to the governor of HMP Wakefield and The Minister of State for Prisons and Probation.
In the report, Miss Wolstenholme said that at around 6.30am on June 10 2019 a prison officer did a roll check and made a "brief observation" of Mr Hoult in his cell and assumed he was watching television.
Ms Wolstenholme said Mr Hoult's cell was unlocked for the morning at around 8am.
Ms Wolstenholme said a second officer had no more than a "fleeting glance" of Mr Hoult for one or two second through the observation panel.
The report states that at around 8.45am a third officer relocked Mr Hoult's cell for the morning session and thought he saw him "appearing to watch television."
Ms Wolstenholme wrote: "Again, it was a glance of no more than one to two seconds through the observation panel.
"At approximately 9.50am the second officer returned to Connor’s cell to seize some unauthorised footwear."
Ms Wolstenholme said Mr Hoult was in the same position as he was when that officer had seen him at 8am.
She said medical evidence revealed Mr Hoult had been dead for a "considerable number of hours."
Miss Wolstenholme wrote in the report: "During the course of the inquest the evidence revealed matters giving rise to concern.
"In my opinion there is a risk that future deaths will occur unless action is taken.
"The evidence revealed prison officers are not obtaining, nor did the prison systems require them to obtain, a response from all prisoners during welfare checks.
"More specifically, during the morning unlock they are not required to, and therefore do not necessarily seek to, obtain a response or otherwise engage with prisoners.
"In particular, no response is required, and therefore not sought, from prisoners who appear to be asleep in bed."
Ms Wolstenholme said a prison service instruction states that "residential prison staff play a key role in spotting any signs of distress and will often be the first to pick up information or signs, and should accordingly engage with prisoners in such a way that facilitates the identification of any concerns or distress."
She said prisons are required to have "clearly understood systems in place for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock."
Ms Wolstenholme said: "In the absence of such systems prisoners in distress, or otherwise a cause for concern, may be missed.
"In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action."
A Prison Service spokesperson said: "We will consider the coroner’s findings and respond in due course."