Prison's weekend mental health care criticised

A prison where an inmate was found dead on the day he was due to be released should offer seven-day-a-week mental health services, a coroner has said.

Nigel John Keenan, 62, was discovered in his cell at HMP Haverigg in Millom, Cumbria, during a routine check by staff in the early hours of 13 March last year, with an inquest concluding he died by suicide.

As part of the evidence given during the hearing, jury members were told the jail did not operate dedicated mental health services at weekends, prompting coroner Robert Cohen to call for changes.

In a letter to the coroner NHS England, which commissions mental health services in prisons, said any learning would form part of a current review.

In their ruling, jurors said Keenan had experienced "heightened stress and worry" ahead of his release, caused by difficulties in finding suitable housing because he was a sex offender.

That "probably" contributed to his death, they found.

The hearing, at Workington in May this year, was told Keenan had been sentenced to five and a half years in prison in June 2022 for offences including engaging in sexual activity with a child.

Keenan's plan to live with his partner upon release fell through and other options were then deemed unsuitable.

Eight days before he was due to leave the prison, it was confirmed he could live with his brother.

Keenan had reported having suicidal thoughts a month ahead of his release.

However, health care workers deemed him not to be at risk and, although he had several meetings with staff, no formal mental health monitoring was put in place.

After hearing details about the set-up of mental health provision at the prison, the coroner said he found it "surprising" teams did not operate at weekends.

He detailed his worries in a prevention of future deaths report - a document used by coroners to highlight issues they believe need to be addressed.

Cohen said an inmate experiencing difficulties during a weekend would be cared for by prison staff "but mental health input would not be available until Monday morning".

He said the lack of support on Saturdays and Sundays was "counterproductive", warning that because Haverigg was a Category D open prison, it did not have enough staff to place prisoners on a constant watch.

That meant anyone requiring regular or constant observation would need to be transferred to a closed jail where there were more guards, a situation the coroner said "risks providing an incentive for prisoners in crisis to play down the true extent of their situation".

In its letter to Cohen, NHS England said it was keen to assure him and Keegan's family the concerns raised had been "listened to and reflected upon".

It said its North West Region Health and Justice team had advised there was a seven-day service at HMP Haverigg, with an 'on call' service over the weekend and a core service delivering Monday to Friday.

It acknowledged there had been confusion about how the weekend service operated but said that had been resolved.

NHS England added a current review of prison healthcare services was due to be finalised in summer 2026, and any learning from the case would be used to inform it.

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