A JURY has ruled that neglect contributed to the death of an Orford man who was found hanged in prison.

Edwin O'Donnell died in October while serving a six year sentence for attempted robbery and assault at HMP Liverpool.

On Thursday, July 13, a jury at the inquest into the 26-year-old's death found that neglect had led to dying in custody.

Liverpool Coroners Court heard that Mr O'Donnell, known as Ned, was placed under hourly observations two days before his death after he deliberately cut his ear with a razor.

In the early hours of Sunday, October 23, he told a prison officer that he was 'going to kill himself before the officers killed him'.

Giving evidence, a prison officer described him as 'paranoid' and said that there had been a 'clear deterioration in his mental state'.

Staff members informally agreed to increase his observation levels but failed to document or effectively communicate this change.

A nurse who then visited Mr O'Donnell referred him for an emergency mental health review to take place the same day, but no assessment was made.

Later that day, Mr O'Donnell told a cell cleaner that he 'would be dead by 8pm'.

The cleaner told a senior officer on duty, but the officer 'failed to escalate this information'.

At 6.15pm, Mr O'Donnell was found unresponsive hanging in his cell.

The jury, before senior coroner for Liverpool and Wirral Andre Rebello, recorded a conclusion of accidental death, contributed to by neglect after a 10-day inquest.

They found that Mr O'Donnell had put himself in the position that caused his death, but that he did not intend to end his life.

In a statement, Mr O'Donnell's family said: "The conclusion will never bring Ned back, but we hope that the findings will mean that changes are made that will save lives in the future.

"We were appalled to hear about the circumstances in which Ned died and are grateful these have been made public.

"The family want to express their gratitude to the prisoners who attended the inquest as witnesses, to the jury for their conclusion and to their legal team."

The inquest heard that Mr O'Donnell had had a 'difficult childhood', having been taken into care aged five before being subjected to sexual abuse in while in foster care.

Anita Sharma, caseworker at charity INQUEST, said: "The litany of gross failures to respond to Ned's fears, mental ill health and vulnerabilities resulted in the avoidable deaths of yet another young man.

"This prison has been the subject of critical inspection reports and jury findings on a number of occasions.

"Through our casework, we have seen similar failings across the prison estate with an ever increasing number of self-inflicted deaths.

"We repeated our call on the government to implement a national oversight mechanism to learn from previous deaths to prevent future deaths.

"There must be a demonstrable commitment to stem these avoidable deaths."

Concerns over the condition of Mr O'Donnell's cell, described as 'not fit for purpose' were also raised by the jury.

Mr O'Donnell had been detained on a segregation unit at HMP Liverpool and had been there for a month at the time of his death.

After making a formal complaint having spent 10 days in a cell without running water, a flushing toilet or a light, he was moved to another room in which the light and bell did not work.

The Ministry of Justice said it took recommendations made by the Prisons and Probation Ombudsman 'extremely seriously' while measures to improve patient safety at HMP Liverpool had been made.

A spokesman said: "This is a tragic case and our thoughts are with Edwin O'Donnell's family and friends.

"HMP Liverpool is introducing a number of steps to improve safety in custody, including improved training for staff so they can better support vulnerable offenders.

"However, we recognise that more can be done which is why we're putting more funding into prison safety, including the recruitment of 2,500 extra frontline officers, and have launched a suicide and self-harm project to address the increase in self-inflicted deaths in our prisons.

"We will now carefully consider the findings of the inquest."

If you have been affected by any of the issues raised in this article call the Samaritans for free on 116123.