Nigel Keenan

I am Mr Robert Cohen, HM Assistant Coroner for Cumbria

On 21 March 2025 an investigation commenced into the death of Nigel John KEENAN. The  investigation concluded at the end of the inquest . The conclusion of the inquest was Suicide 1a Hanging

The jury’s findings in respect of Mr Keenan’s death were as follows: Death by hanging [REDACTED] at HMP Havering. At a time between 8 pm on 12th March 2025 and the time of being found: 3:15 am 13th of March 2025. Time of death officially recorded by North West ambulance service: 4:20 am 13th of March 2025. As John’s release date approached issues arose regarding his life after prison and how restrictions imposed due to the nature of his offence could impact this. Finding suitable housing was proving problematic. Only eight days prior to release John was finally notified that he would be able to reside with a family member. However it is probable that the heightened stress and worry of this matter contributed more than minimally to his death. Other possible contributing factors to the stress and anxiety John was facing at this time was a recent relationship breakdown and financial worries. The week before John’s death intelligence suggested John was planning to do something that would shock the prison. Prison staff interpreted this as John being a risk of absconding. John had mentioned, a month earlier, that he was experiencing suicidal thoughts. However after following this up with healthcare providers he was not deemed a risk. When questioned John denied making the comment. Given the prior mention of suicidal thoughts and then the threat of doing something to shock the prison, a simple questioning of whether he said this with no further exploration could have been a missed opportunity. However HMP Haverigg have demonstrated they have multiple avenues of support available some of which John chose not to engage with.

During the course of the inquest the evidence revealed matters giving rise to concern. In my  opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. In the course of hearing evidence in this inquest I was told that: 1) Mental health provision is  only commissioned within HMP Haverigg during the week and is not available at the  weekends. I was told that in the event that a prisoner experienced crisis during the weekend  they would be cared for by prison staff using the ACCT procedure, but that mental health input would not be available until Monday morning. 2) Because HMP Haverigg is a Category  D ‘open’ prison it has far fewer staff available to monitor prisoners. As such it is not able to  place prisoners on ‘constant watch’. As a result if a prisoner requires very regular or constant  observation (as a result of being in crisis) they would have to be transferred to a closed  prison. 3) This means that prisoners who are in crisis have something of an incentive to deny  their intent to self harm because to admit to it would result in their being transferred to a  closed prison. I am concerned that the decision not to commission 7 day a week mental health support at  HMP Haverigg is therefore counterproductive. Because of the limited number of prison  officers at the establishment it gives rise to a higher risk than would be the case at a closed  prison. In particular, it risks providing an incentive for prisoners in crisis to play down the true  extent of their situation.

In my opinion action should be taken to prevent future deaths and I believe that, as  healthcare in prisons is directly commissioned, NHS England have the power to take such  action.