'Missed opportunities' when HMP Humber prisoner died in jail after worried wife's phone call

Keith Turner told healthcare staff on four occasions in one month that he was having suicidal thoughts

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A prisoner at HMP Humber told staff on four occasions he was suffering from suicidal thoughts and his wife raised the alarm on the day he died. Keith Turner was not put on the Prison Service suicide and self-harm monitoring and healthcare staff did not flag any concerns about his suicidal thoughts to prison staff. The clinical reviewer found many missed opportunities for the mental health team to support Mr Turner.

In her report into Mr Turner's death, Sue McAllister CB for the Prisons and Probation Ombudsman said: "On the morning of Mr Turner’s death, around an hour before he was found, his wife called the prison’s switchboard and asked if someone could check on her husband because she had not heard from him that morning. "I am concerned that the switchboard operator did not refer Mr Turner’s wife to the Safer Custody hotline. This was a missed opportunity for someone to check on Mr Turner.



"I am also concerned that there was a delay in sending an emergency ambulance to treat Mr Turner, as prison staff initially gave insufficient information to the ambulance service for them to treat the call as an emergency." Mr Turner had been jailed for three years and nine months at York Crown Court in March 2019 after he pleaded guilty to engaging in controlling or coercive behaviour in an intimate relationship. He was previously sentenced to 16 months imprisonment in 2012 for abusive behaviour towards two other women.

On 19 March that year, Mr Turner was moved from HMP Hull to HMP Humber. In December, he told healthcare staff he had suicidal thoughts but his wife and daughter prevented him from taking his life and he was "adamant" he would not harm himself. At 8.

53am on 9 January 2020, Mr Turner’s wife telephoned HMP Humber’s switchboard and asked if someone could check on her husband as she had not heard from him that morning. He normally called his wife before 8am every weekday, except Bank Holidays. The operator incorrectly told her that as Mr Turner had contacted her within the last seven days, they could not ask for an update, according to the report.

They did not refer Mr Turner’s wife to the prison’s Safer Custody hotline. READ MORE: Keep up to date with all the latest breaking news and top stories from Hull with our free newsletter At approximately 9.55am, a prisoner found Mr Turner on the floor of his cell in a pool of blood.

He had a self-inflicted wound and was pronounced dead by an air ambulance doctor at 10.34am, despite efforts from prison staff and paramedics to resuscitate him. In her report, Ms McAllister expressed condolences to Mr Turner’s family and friends.

Although the report was carried out in October 2020, it could only be published now due to waiting for the outcome of the inquest into his death. At the inquest, held from 16 to 23 September 2024, the jury concluded Mr Turner died by suicide. A Prison Service spokesperson said: "Our thoughts remain with the friends and family of Keith Turner.

Since his death, HMP Humber has made significant improvements, including better communication between healthcare and prison staff, enhanced training for managing prisoners at risk, and the introduction of a dedicated safer custody line.".