Jury told: think again on prisoner Sammy Arthur Christie's death verdict

Published: 17 September, 2010
by CHARLOTTE CHAMBERS

A JURY were told by a coroner to go back and reconsider their verdict after ruling that an inmate at Pentonville Prison died from “a lack of communication” and a “failure of the system”.

The dramatic proceedings took place at St Pancras Coroner’s Court yesterday (Thursday) during an inquest into the death of Sammy Arthur Christie, 34, at the Caledonian Road prison in January.

The jury returned a narrative verdict that Mr Christie died from self-suspension by a ligature after rejecting a verdict of suicide or misadventure. But in their inquisition – the record of the inquest which the jury are legally bound to write – they made their findings against the prison service. 

The jury foreman stated that Mr Christie “died as a result of self harm while in custody due to, A) on the whole a lack of communication [and] B) failure of the system”.

Following legal discussions with the lawyer for the Ministry of Justice and Camden and Islington Foundation Trust, responsible for mental health care in the prison, coroner Dr Andrew Reid then called the jury back to redirect them. He said that, while Mr Christie’s key worker failed to share his medical notes with colleagues – instead, putting them in a drawer unread – the prisoner was still seen by healthcare professionals. 

He added: “There is no justification to describe there was a failure of the system. There were failings, there was a system, but these were individual errors rather than the system.”

Dr Reid added that the jury could make findings of fact only on points that directly related to and caused Mr Christie’s death.

The jury then retired for 10 minutes before returning a new finding of fact that Mr Christie “died as a result of self-harm while in custody”.

Earlier Mr Christie’s mother, Barbara, had quizzed her son’s key worker, Amos Moijueh, a psychiatric nurse, on the findings of a report compiled by the Prisons and Probation Ombudsman (PPO), an independent body which investigates all prison deaths.

The report stated that Mr Moijueh had told investigators he had no induction into his job, a claim he denied in the witness box, and that that, along with his inexperience, was the reason he made mistakes in Mr Christie’s care. 

The report said he asked Basildon Hospital for notes on Mr Christie, but failed to read them or order an administrator to type them into a computer system shared by all staff. The hospital notes revealed Mr Christie had a history of self-harm and depression.

Mrs Christie said: “[The report] says [of] the information from Basildon Hospital, you never passed it on or entered it into the computer. You put it in a drawer.” Mr Moijueh denied that and said he put it in a folder and left it on his desk.

Mrs Christie then asked, in reference to notes about her son’s mental health: “Did you read any of this?” He said: “No ma’am, I didn’t,”

She replied: “But surely that’s part of your job?” 

He said: “It is.”

Mr Moijueh admitted he would have treated Mr Christie’s care needs differently now, following more than a year of experience in the job. “At the time, I was new in the job,” he said.

It also emerged that attempts to deal with Mr Christie’s grief over his father’s death three years earlier had not been dealt with, despite requests from the prisoner to see a bereavement counsellor. 

Mr Christie, who suffered from bi-polar disorder, was on remand at Pentonville for criminal damage and would have in all likelihood been released from prison within weeks, the court heard. 

The coroner speculated whether the prison should face criticism for putting him in the segregation unit just two days after he was found with a self-made ligature.

Diane Henderson, from the PPO, told the court that eight of nine recommendations made in the report in the wake of Mr Christie’s death had been adopted by Pentonville’s management team.