Tyrone Givans' inquest: Family says 'failures' of Pentonville and Care UK 'contributed' to death
PUBLISHED: 12:58 23 January 2019 | UPDATED: 12:24 24 January 2019
The family of a man found hanged in Pentonville prison has thanked the jury for acknowledging how "failures" made by prison and health care staff "contributed" to his death.
Tyrone Givans, 32, was found hanged in his cell at the prison on February 26.
The profoundly deaf inmate had handed himself into Islington police on February 5 after causing ABH, but threatened to kill himself if jailed.
However, his comments were recorded as a threat to self-harm, not take his own life, and he was held at Pentonville on remand – without his hearing aids.
The jury delivered a narrative determination at St Pancras Coroner’s Court on Tuesday, which stated: “[Tyrone] had significant and long-standing mental health problems, including depression and anxiety – he also suffered from chronic alcoholism, substance abuse [and] he was profoundly deaf.
“We find, throughout his custody, these issues were insufficiently processed and addressed by the prison and healthcare services.
“We find communication between members of staff inconsistent and unsatisfactory.
“We find that the IT systems used for storing prisoners’ records was inadequate, and best practice and established procedure was not followed,
“Collectively, these factors resulted in Tyrone Givans’ needs not being met and contributed to his death.”
Tyrone’s left his hearing aids at his ex-girlfriend’s house, where he shouldn’t have been staying due to a restraining order – and was said to have been “ecstatic” when one was eventually recovered and he was given it on February 21.
In their toxicology report, Dr Rosa Cordero and Dr Susan Paterson found a small trace of cocaine, a “minimal” amount of alcohol and evidence of antidepressants, prescribed while in prison, in Tyrone’s system.
They found no trace of Spice, which his former cell mate, Ali Khan, claims Tyrone took. But there are 100 different varieties of the drug, smuggled into prisons in liquid form, and toxicologists can currently only test for six.
Tyrone was assessed on his first night in Pentonville, February 7, when an officer observed he was “very confident and clear” and asked about a medical note from 2014 when Tyrone was on “constant watch” for suicide. Tyrone allegedly dismissed this as “a long time ago”.
The officer concluded he wasn’t suicidal but said: “I would have approached it differently if I had known it was not simply a threat to harm himself but a threat to kill himself.”
A mental health nurse assessed Tyrone the same day and decided to refer him to the mental health and substance abuse team – but this never happened because “he didn’t press the right button on the computer system”.
Filing errors also created two separate prison records for Tyrone, under different spellings of his name.
The court heard how the nurse didn’t read the PER but he said he “definitely should have”.
The jury was also told none of the individuals referred Tyrone to Pentonville’s equalities officer – who was best placed to help get his hearing aids, but they did eventually find out.
In evidence, the equalities officer said they reported Tyrone’s lack of hearing aids to the deputy head of health care who said he’d pick it up. But the coroner said there was a “conflict of evidence”, as he said he had no recollection of the conversation.
Dr McAllister saw Tyrone on February 8, when he proscribed him antidepressants. He claims he asked him if he was suicidal but made no record of this conversation. He later saw him again about “a lump” on February 22 but did not review his mental health.
Senior coroner Mary Hassell told the jury she thought “every health care staff member who saw Tyrone” would say they should have made further enquiries.
Tyrone’s family said: “We are pleased the jury have rightly acknowledged the failures of the prison and Care UK which contributed to Tyrone’s death.
“Tyrone was profoundly deaf and very vulnerable.
“He was scared without his hearing aids and we believe he suffered without support at HMP Pentonville.
“We hope to now move on and grieve the sad and avoidable loss of Tyrone.”