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A coroner has recorded a verdict of unlawful killing after a prison inmate took his own life.

Robert Fenlon, from Northampton, was found in his cell at Woodhill Prison, Milton Keynes, on 5 March 2016 and taken to hospital, where he died.

A jury at Milton Keynes Coroner's Court concluded his death was an "unlawful killing contributed to by neglect".

It found the jail's leadership team did not adequately respond the month before his death when he passed a note under his cell door that indicated his despair and that he was contemplating suicide.

The jury found there were failures to refer him to the mental health team and a serious failure in not placing him under constant supervision.

The 35-year-old was known to suffer with drug and alcohol dependency and to have mental health problems.

According to a document released by the coroner, Mr Fenlon asked early in his stay to be referred to be mental health services but the request was declined.

In February a safety plan for prisoners at risk of suicide or self-harm was opened after he passed the note under his door.

However, the effectiveness of this assessment was heavily criticised.

The court found: "There was no adequate system in place to allocate case managers by the leadership team.

"The first case review was not multi-disciplinary and did not consider all the relevant risk information."

'Not taken seriously enough'

On 3 March 2016 Mr Fenlon was discovered in his cell after a failed attempt to take his own life.

Following this, his risk of suicide was not correctly identified or assessed and the prison failed to put him on constant supervision.

The next day a noose was found in his cell but the report said it was not reported correctly and "not taken seriously enough".

According to the coroners: "Robert was told a mental health referral was being made. This did not happen.

"Neither of the events on 3 or 4 March resulted in any further measures to preserve Robert’s safety."

It was also suggested by the court there had been a falsification of an official document after Mr Fenlon's suicide attempt on 3 March.

The father was found in his cell on 5 March.

The report blamed: "Inadequate training, lack of communication, inadequate risk assessment and failure to follow related processes.

"There was not adequate staffing oversight, oversight of senior health care assistant and serious failure by the prison to implement previous recommendations."

A Prison Service spokesperson said: “Our thoughts remain with the family and friends of Robert Fenlon.

"We will consider the findings of the coroner’s report and will respond with our actions in due course.”

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