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Richard Walsh, who took his own life in HMP Belmarsh, should have been in a psychiatric hospital.
The jury found the cause of his death was suicide ‘with neglect constituted by the gross failure to provide basic medical care’.
The 43-year-old was found hanging in his cell on July 19, 2015.
The jury found that Richard should have been detained in hospital and said: ‘It is more likely than not that if Mr Walsh had been detained in a hospital instead of Belmarsh he would not have killed himself.’
As well as being diagnosed with depression, he had a history of trying to take his own life and had previously been detained in a psychiatric hospital under the Mental Health Act.
At the time of his death he had been confined alone in his cell for more than 23 hours per day, without time in the open air or any contact with other prisoners.
Specifically, the mental health practitioner and two psychiatrists who saw him at a police station after his arrest failed to:
n Secure information about him from the custody record or custody officer, in particular about his delusional behaviour and obsession with a female police officer.
n Investigate the possibility of speaking with Walsh’s relatives.
n Section him under the Mental Health Act.
After the hearing, Walsh’s mother Linda Walsh said: ‘It’s been heart-breaking.
‘While I welcome the jury’s conclusions, to hear of the failings the jury have found which contributed to Richard’s death makes me feel very sad.
‘These conclusions will not bring Richard back, but more measures need to be put in place to try to stop this happening again.’
Deborah Coles, director of INQUEST, a charity that provides expert views on deaths in custody, said: ‘Richard should never have been in prison in the first place, but in a secure psychiatric unit.
‘The opportunity to safeguard him was lost by the failure to adequately assess him after his arrest.
‘To put somebody with serious mental health issues in prison, in what amounts to solitary confinement for more than 23 hours a day, is nothing short of inhumane.’
Linda Walsh’s solicitor, Helen Stone of Hickman and Rose, added: ‘The jury’s finding of neglect is a damning indictment of the way in which the Mental Health Act assessment was conducted.
‘It is clear that lessons need to be learned by all those involved in Mental Health Act assessments, especially in a police station setting.’
Walsh had been homeless for four months and was living in a tent in woods in Southleigh Road, Havant when he was arrested over the stabbing of the boys, 12 and 13, on June 26 last year.
Police held him in custody at Waterlooville station for eight hours – after arresting him at 3pm – before he was assessed by an approved mental health practitioner.