A 'troubled' young man died after jumping from the eighth floor of a building just days after his mum died.
Robert Mulvey, 32, had been living with his dad when he jumped from the building. He died in hospital that evening.
Mr Mulvey had been released from HMP Wealstun, near Wetherby, Leeds, four days before his death on February 12, 2019. A Prisons Ombudsman report published this week has raised a number of concerns about what happened when he was in custody and during his impending release.
The Ombudsman, Sue McAllister, said: "This is a very sad case of a troubled man. Mr Mulvey had serious, long-standing mental health and substance abuse problems.
"Prison Service staff appropriately started suicide and self-harm prevention procedures two weeks before his release from prison, and several aspects of his management were positive.
"However, there were also some basic aspects of the procedures that prison staff did not comply with. And, in view of Mr Mulvey’s impending release from prison and his mother's unexpected death a few days beforehand, I am disappointed that his family were not informed of or asked to contribute to the suicide and self-harm prevention procedures.
"I am also concerned that, although Mr Mulvey had been prescribed antipsychotic medication for several years, no one at Wealstun or HMP Leeds (where he lived before being transferred to Wealstun) referred him to their mental health teams on his arrival, contrary to national guidelines. There are also some aspects of the discharge arrangements for dual-diagnosis prisoners that require review."
The report noted that Mr Mulvey had been sentenced in December 2018 to seven months and 12 days in prison. He had been diagnosed with schizophrenia several years earlier and was prescribed antipsychotic medication in the community, although he did not always take it. He also misused drugs while in the community.
While in custody at Wealstun, Mr Mulvey told a prison nurse that voices had told him to harm himself, and that he had poured boiling water on his hand and banged his head on a wall. The nurse started suicide and self-harm procedures, known as ACCT.
A prison psychiatrist prescribed antipsychotic medication. The next day, Mr Mulvey cut himself. He later told prison staff that this was an attempt to take his life.
The Ombudsman said: "Although Mr Mulvey had received treatment in the community for mental ill health for several years, he was not referred to prison mental health teams on arrival at either Leeds or Wealstun. Mr Mulvey received appropriate care after he was later referred to the mental health team at Wealstun, although we found that aspects of his release arrangements require review."
The Ombudsman's report made a number of recommendations to the prison authorities. Following Mr Mulvey's death, the Ombudsman's family liaison officer contacted his father to explain the investigation and to ask if he had any matters he wanted the Ombudsman to consider.
Mr Mulvey’s father said that the prison did not tell him that they considered his son was at risk of suicide or that he had harmed himself in prison.
Read next:
